ACOG releases new all-in-one resource on vaccinations in pregnancy

ACOG recently released the new all-in-one resource to help obstetrics care provider ensure that all pregnant women receive the vaccines they need—not only protect themselves but also their unborn child again preventable diseases.

ACOG recommends that all obstetrician should routinely assess the immunization status of their pregnant patients and address their concerns about vaccine safety during prenatal visits.

"Studies consistently demonstrate that when the recommendation and availability of vaccination during pregnancy comes directly from a woman's obstetrician or other obstetric care providers, the odds of vaccine acceptance and receipt are 5-fold to 50-fold higher," write the authors of ACOG committee opinion on vaccination.

During the first prenatal visit, the provider should assess the woman’s immunity status against rubella and varicella. If the woman is not immunized against measles-mumps-rubella (MMR) or varicella, she needs to get these vaccines in the postpartum period, because both the MMR and varicella vaccines are live attenuated vaccines and are contraindicated in pregnancy.

Women who are pregnant during influenza season should receive the flu vaccine during each pregnancy. Other vaccines that are to be given during each pregnancy are tetanus toxoid, reduced diphtheria toxoid and acellular pertussis given as early as possible in the 27 to 36 weeks of gestation window.

All live attenuated vaccines are contraindicated in pregnancy while inactivated virus, bacterial vaccines, or toxoids are entirely safe in pregnancy as indicated by a growing body of research data.

Vaccines that are given in every pregnancy

Inactivated Influenza

Tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap)

Maybe given in pregnancy in particular population

Pneumococcal vaccine

Hepatitis A

Meningococcal disease

Hepatitis B

Contraindicated in pregnancy

Measles-mumps-rubella (MMR)

Varicella

Initiated during the postpartum period or when breastfeeding or both

HPV vaccination series

Inactivated Influenza

Tetanus toxoid reduced diphtheria toxoid and acellular pertussis (Tdap)

Pneumococcal vaccine

Hepatitis A

Meningococcal disease

Hepatitis B

Measles-mumps-rubella (MMR)

Varicella

Vaccines in development

Some vaccines that can significantly reduce infectious disease in neonates are in the process of development and are likely to become part of the maternal/newborn arsenal shortly. It includes:

Streptococcus agalactiae, or group B Streptococcus (GBS)

Respiratory syncytial virus (RSV)

ACOG committee opinion

Ob/Gyn Updated Facebook page

Vaccinations before, during and after pregnancy.

Prenatal screening

Women who are planning to become pregnant should make sure that they are up to date on their immunizations. This will protect them and the unborn child from many diseases.

The measles, mumps, rubella, and chickenpox (varicella) vaccines are particularly important for women of childbearing age, as these cannot be given when pregnant. If a woman is infected with any of this in pregnancy, particularly first trimester, it results in adverse pregnancy outcome. 

Patients should check with their physician, who can request a blood test to see the blood levels of antibodies against these viruses, because of prior vaccination or prior history of disease itself.

MMR- If you need to get the vaccine for Rubella, avoid getting pregnant for at least a month after receiving the MMR.

Varicella- Similarly, if you are not immune to chickenpox, get vaccinated at least a month before getting pregnant.

HPV Vaccine- The human papillomavirus (HPV) vaccine is recommended for nonpregnant girls and women 9 to 26 years of age. It is contraindicated during pregnancy, although evidence suggests it is safe if pregnant women receive it inadvertently.

Hepatitis B- A woman should get tested for anti-HBs before she is pregnant to see whether the vaccine was well taken and she is immune to infection.

Vaccines during pregnancy

The tetanus, diphtheria, acellular pertussis (Tdap) vaccine is recommended for every pregnant woman during each pregnancy. It should be given as early as possible between 27 and 36 weeks of gestation, to facilitate the passive transfer of maternal antibodies. Infants exposed in utero to Tdap vaccine were better protected against pertussis during the first year of life than infants not exposed in utero.

Influenza (flu)- Every pregnant woman who is pregnant around the influenza season should be vaccinated against the seasonal flu as she is at high risk for developing flu complications. The vaccine has no adverse effect on fetus, on the contrary the unborn baby is protected against flu for first 6 months of life, till the baby is eligible to receive the vaccine.

The nasal spray influenza vaccine is contraindicated as it is made of live virus.

Vaccines for special circumstances

Hepatitis A- Pregnant woman who is at risk for developing Hepatitis A should receive the vaccine as the virus can be passed on to fetus.

Hepatitis B- It is only recommended for pregnant women who are at high risk for developing the infection like unimmunized women who live with someone infected with hepatitis B and for completing the series if started before becoming pregnant.

Poliomyelitis- Although polio has been eradicated from most developed and some developing countries, polio vaccine is usually not given in pregnancy unless travel to an area where polio is prevalent is unavoidable. In such circumstances, she may receive the inactivated polio vaccine (IPV). 

Pneumococcus- Ideally the vaccine is given before pregnancy, but  if woman is at high risk for pneumococcal infection, the vaccine appears to be safe if given in second and third trimester.

Varicella- Because the effects of the varicella virus on the fetus are unknown, it is contraindicated in pregnant women.

Vaccines for travel

Yellow fever- May be given if benefit outweigh risk. 

BCG- contraindicated

Typhoid- Inadequate data to make any recommendations

Rabies – Pregnancy is not considered a contraindication for post-exposure prophylaxis. If risk of exposure is substantially high, pre-exposure prophylaxis could be considered.

Passive Immunization during pregnancy

No known risk exists for the fetus from passive immunization of pregnant women with immune globulin preparations.

Prenatal screening

Every Pregnant woman should be tested for immunity to rubella and varicella and be tested for the presence of HBsAg during every pregnancy. Women who are found susceptible to rubella and varicella should be vaccinated immediately after delivery.

If a woman is found to be HBsAg positive, the infant should receive HBIG and begins the hepatitis B vaccine series no later than 12 hours after birth.

Breastfeeding and vaccines.

Inactivated and live-virus vaccines are not contraindicated in pregnant woman, although the virus can replicate in mother, it is not excreted in human milk.

Small pox and yellow fever vaccines are contraindicated in lactating mother, although if travel to an area where Yellow fever is endemic is imminent, it can be given. 

Source: CDC Guidelines for Vaccinating Pregnant Women

The Mothers Index: Quantifying Mothers round the world.

savethechildren.org

Mother’s Day is a holiday celebrated to honor motherhood throughout the world. Although it is observed in different forms and at different times worldwide, the basic thought  behind it remains the same. The American incarnation of Mother’s Day was created by Anna Jarvis in 1908 and became an official U.S. holiday in 1914. It traditionally involved presenting the mothers with flowers, gifts and cards.

Beside celebrating love by giving gifts, we all have a moral obligation to protect the health of mothers round the world. It does not end with only making child birth safe for her but continue well beyond that into her geriatric years by building systems that are effective, inclusive and sustainable. Many diseases like breast and ovarian cancer, osteoporosis and other chronic diseases can be prevented or treated completely by early diagnosis.

Improving maternal health is among the most challenging of the Millennium Development Goals. In commemoration of Mother’s Day, Save the Children  published its 16th annual State of the World’s Mothers report; Norway rose to the top of the list while Somalia remained last for the second year in a row. 

The five indicators in the 2015 Mothers' Index of 179 countries are the lifetime risk of maternal death; children's well-being; educational status; economic status and political status, measured by women's participation in national government.

Every day, 17,000 children die before reaching their fifth birthday.

Best countries for mothers: (Top five in Mothers index)

Norway

Finland

Iceland

Denmark

Sweden

Worst countries for mothers: ( Last five in Mothers index)

Somalia

Democratic Republic of the Congo

The Central African Republic

Mali

Niger

The United States continues to be outpaced by smaller countries in its treatment of its mothers, dropping two spots to 33rd place.

There are nearly 2 billion mothers in the world (85.4 million in the U.S.) and 4.3 new mothers are added every second.

Quite a large number of children in developed countries live with one parent, most likely mother. Educated mothers are more likely to insist on their children being educated, specially girls. Their children are more likely to continue education and study for 2 hours more compared to illiterate mothers

Women all over the world are delaying childbirth, the average age of woman having the child for first time rose from 25 to 26 recently in US and it is 29 in other developed countries such as Japan and Switzerland according to data released by Centers for Disease Control and Prevention (CDC).

Maternal Mortality Rate

According to WHO:

The current MMR is 216 deaths per 100,000 live births.

Every day, approximately 830 women die from preventable causes related to pregnancy and childbirth.

99% of all maternal deaths occur in developing countries where 1/3 of births are performed by unskilled professional.

Young adolescents face a higher risk of complications and death as a result of pregnancy than other women.

One in 4 women who die during childbirth is simply because of post-partum hemorrhage, which is preventable at meagre cost of 99 Cents.

Between 1990 and 2015, maternal mortality worldwide dropped by about 44%.

Between 2016 and 2030, as part of the Sustainable Development Goals, the target is to reduce the global maternal mortality ratio to less than 70 per 100 000 live births.

MMR across the globe 

The top 5 countries in the world with lowest maternal mortality rates are Norway, Australia, Iceland, Sweden and Denmark.

The 5 countries with highest maternal mortality rates are South Sudan, Chad, Somalia, Sierra Leone and Burundi.

Fertility rates around the world.

The current fertility rate is 2.5 children per woman. Africa remain the region with highest fertility at 4.7 children per woman while Europe has the lowest fertility at 1.6 children per woman.

The world’s highest fertility rates exist in Niger, with an average of 7.75 children born per women. 

The world’s lowest fertility rates are found in Japan, South Korea, Taiwan, and Singapore, where an average of 1.2 children are born per woman.

The net reproduction rate is the average number of daughters that would be born to a woman taking into account the prevailing levels of fertility, female mortality and the sex ratio at birth. The current reproduction rate globally is 1.1 surviving daughters per woman except for Africa, where the net reproduction rate is 1.9 This means that, on average, each African mother is replacing herself with nearly two daughters, which leads to fast population growth.

Net Reproduction Rate 

Statistics are far more than numbers. It is the human despair and lost opportunities behind these numbers that call for changes to ensure that mothers everywhere have the basic tools they need to break the cycle of poverty and improve the quality of life for themselves, their children, and for generations to come.