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

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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