Vaccines, Pregnancy

and Breast-feeding
Support for this program is made possible by the AAFP Foundation through a grant from Pfizer Inc.
Developed for AFMRD by
Gail Colby, M.D. and Wendy Biggs, M.D.
Midland Family Medicine Residency
2010

Ehab Molokhia, MD and Gerald Liu, MD

University of South Alabama Family Medicine Residency
Updated 2012

Vaccines, Pregnancy and Breast-feeding

Objectives
• Medical knowledge
– List 3 most common live attenuated vaccines
– State vaccines that are CONTRAINDICATED
for administration during pregnancy
– List the vaccine that Advisory Committee on
Immunization Practices (ACIP) recommends
be given to all pregnant patients
– Recognize vaccines high-risk women should
receive

Vaccines, Pregnancy and Breast-feeding

Objectives
• Patient care
– Assess a pregnant woman’s immunization
status
– Administer indicated tetanus-diphtheria-
pertussis vaccination
• Interpersonal communication
– Recognize the prenatal visit as an
opportunity to discuss vaccine indications
with patient
Vaccines, Pregnancy and Breast-feeding
Vaccines in Pregnancy
• The pregnant woman is at increased
risk for severe illness from some
vaccine-preventable illnesses
– Example: H1N1 influenza in 2009-10
• Pregnant women who contracted H1N1 in 2009
were more likely to need hospitalization and
had increased morbidity and mortality

MMWR Morb Mortal Wkly Rep. 2010 Mar 26;59(11):321-6. 2009 pandemic influenza A
(H1N1) in pregnant women requiring intensive care – New York City, 2009.

Vaccines, Pregnancy and Breast-feeding .

Vaccines in Pregnancy
• Pre-conception counseling on
immunizations is ideal
• If pre-conception counseling not done,
prenatal visits are opportunity to discuss
and administer recommended
vaccinations

Vaccines, Pregnancy and Breast-feeding

Vaccines in Pregnancy
• Passive immunity by trans-placental
transfer of antibodies may protect
vulnerable neonates
– Vaccinating pregnant women in third
trimester for influenza
• Decreased respiratory illness with fever 36%
within first 6 months of life
• Infants born to vaccinated women had 63%
decreased incidence of lab-confirmed influenza

Zaman Z, et al. Effectiveness of maternal influenza immunization in mothers and infants. N Engl J Med; 2008; 359:1555-64.

Vaccines, Pregnancy and Breast-feeding

Vaccine Benefits in Pregnancy
• Benefits outweigh risks when
– Likelihood of disease exposure is high
• Example: Pertussis in the household
– Infection would pose a risk to mother
• Example: H1N1 influenza
– Infection would pose a risk to fetus
• Example: Maternal hypoxia from severe influenza
– Vaccine is unlikely to cause harm
• Example: Inactivated vaccines
Vaccines, Pregnancy and Breast-feeding
Obstacles to Vaccines in Pregnancy
• Mothers may refuse vaccinations
– Wish to avoid any potential “exposures” to
fetus in utero
– Public misconception of vaccines
• Perceived as “dangerous”
– e.g. H1N1 influenza vaccine in 2009
– Thimerosal
• ACOG states (2009) “benefits of vaccines
outweigh any unproven potential concerns about
traces of thimerosal preservative”
Vaccines, Pregnancy and Breast-feeding
Obstacles to Vaccines in Pregnancy
• Public perception that only “FDA-
approved” vaccines for pregnancy
should be given
– None are pregnancy category A
– Only bivalent HPV is pregnancy category B
– Anthrax is category D
– All others are category C
• H1N1 and seasonal influenza are category C

Vaccines, Pregnancy and Breast-feeding

Guidelines for Vaccinating
Pregnant Women
• For most vaccines
– Recommendations from the Advisory Committee
on Immunization Practices (ACIP)
• Published update May 2007
• Available at
www.cdc.gov/vaccines/pubs/pregguide.htm
• Updates for specific vaccines published on-line
– e.g. H1N1 influenza (www.cdc.gov/h1n1flu)

Vaccines, Pregnancy and Breast-feeding

ACIP Vaccine Recommendations
in Pregnancy
• Vaccines classified as
– “Recommended”
– “Consider if otherwise indicated”
– “Recommended to avoid”

Vaccines, Pregnancy and Breast-feeding

Vaccine Safety in Pregnancy
• Live vaccines are CONTRAINDICATED by
ACIP during pregnancy
• However, risk of live vaccines is theoretical
– No direct evidence against transmission of any common
live vaccines (e.g. MMR, Varicella, nasal influenza)
• Ref: www.cdc.gov/vaccines/pubs/preg-guide.htm#19

– Smallpox (vaccinia) only vaccine proven to

be transmitted to fetus (vaccine not
distributed)
– Avoidance of live vaccines is based on
theory only
Vaccines, Pregnancy and Breast-feeding
Vaccine Safety in Pregnancy
• No evidence of fetal risk with
– Inactivated vaccines
• e.g.Inactivated influenza
– Bacterial vaccines
• e.g. Meningococcal
– Toxoid vaccines
• e.g. Td (tetanus-diphtheria)

Vaccines, Pregnancy and Breast-feeding

Live Vaccines
• Measles, Mumps and Rubella (MMR)
• Varicella (chickenpox)
• Live attenuated influenza (intranasal
spray flu vaccine)
• Zoster (for shingles)
• BCG (for tuberculosis, not done in U.S.)
• Vaccinia (smallpox)
Vaccines, Pregnancy and Breast-feeding
Live Vaccines and Pregnancy
• Avoid pregnancy for 28 days after MMR
and/or varicella vaccine
• If found to be pregnant when vaccine
given, counsel patient on theoretical risk
– Not an indication for termination

Vaccines, Pregnancy and Breast-feeding

Case
25 year old G2P1 woman presents for
her first prenatal visit. Your nurse
ordered routine prenatal lab tests. Her
blood type is A negative. She is rubella
non-immune. She tells you she was
rubella immune last pregnancy. You
review her immunization history.

Vaccines, Pregnancy and Breast-feeding

Case
What questions do you need to ask her?

Vaccines, Pregnancy and Breast-feeding

Case Questions
1. Did she have routine childhood
immunizations?
– Yes, most states require children to have up-to-
date immunizations prior to school entry
2. Did she get booster shots as an
adolescent? Which ones?
– Got tetanus-diphtheria (Td) at 14 years old

Vaccines, Pregnancy and Breast-feeding

Case Questions
3. Did she have chickenpox as a child?
– Yes
– If she was unsure about her chickenpox
status, Varicella IgG should be checked
– If negative – varicella vaccine postpartum
at same time as MMR and Anti-D
(Rhogam®)

Vaccines, Pregnancy and Breast-feeding

Case Questions
4. Why is the patient non-immune to rubella?
– Responded to MMR but antibody titer now at
low level
• Rubella antibody may decline over time below detection
level of standard tests
– If non-immune in her first pregnancy, perhaps
failed to respond to original immunization
series
• Occurs 1-2/1000 even with proper timing of series

Vaccines, Pregnancy and Breast-feeding

Case Questions
5. Is she at increased risk for rubella?
– Most likely NOT
– Even with waning immunity, increased
susceptibility to rubella does not occur
• Studies of people with “lost” detectable rubella
antibody
– Most had antibody levels with more sensitive tests
– Respond with rapid IgG antibody rise to booster
after re-vaccination with MMR

Vaccines, Pregnancy and Breast-feeding

Measles, Mumps
and Rubella (MMR)
• She is Rh negative, received Anti-D
Immunoglobuin (Rhogam®) at 28 weeks,
and now needs Rhogam® post-partum
• How does this affect giving MMR?
– Anti-D Immunoglobuin (Rhogam®) can be
administered in a different limb simultaneously
with MMR
– If not given simultaneously, then MMR should be
given 3 months after Anti-D Immunoglobuin
(Rhogam®)
Vaccines, Pregnancy and Breast-feeding
Measles, Mumps
and Rubella (MMR)
• Your patient receives Rhogam® and an
MMR simultaneously after delivery
• Should you do any follow-up?
– Yes. Rubella IgG antibody titers should be
checked 3 months later for immunity.

Vaccines, Pregnancy and Breast-feeding

Measles, Mumps
and Rubella (MMR)
• How does an Rh negative infant change
the mother’s management?
– She does not need Anti-D Immunoglobulin
(Rhogam®) post-partum
– She still needs MMR
– Titers for rubella IgG should be checked
6 weeks after MMR given

Vaccines, Pregnancy and Breast-feeding

What about Tetanus-
Diphtheria (Td)?
• Health care providers should assess a
pregnant woman’s tetanus immunization
status.
• Your patient got a tetanus shot at 14 years
old (11 years ago)
– Indications to update tetanus immunization
• No Td vaccination within the last 10 years
• No completed primary childhood series (4 or 5
doses of pediatric tetanus-diphtheria)
Vaccines, Pregnancy and Breast-feeding
What about Tetanus-
Diphtheria (Td)?
• Is your patient’s tetanus protection
“presumed sufficient? ”
• “Presumed sufficient” if
– Younger than 31 years and received complete
childhood series and at least 1 booster of Td as an
adolescent or adult
– Older than 31 years and received complete
childhood series and at least 2 Td boosters.
– Tetanus titer protective (>0.1 IU/ml by ELISA)

Vaccines, Pregnancy and Breast-feeding

What about Pertussis?
• Pertussis incidence is increasing
• Use of Tdap to booster tetanus,
diphtheria, and pertussis is a “consider
if otherwise indicated” recommendation
by ACIP
• Pregnancy is NOT a contraindication for
use of Tdap

Vaccines, Pregnancy and Breast-feeding

What about Pertussis?
• Should your patient get Tdap or Td during
pregnancy?
• What other information do you need to
know?
– Where does she work?
– How old is her other child?
– Is there pertussis in the community?

Vaccines, Pregnancy and Breast-feeding

Pertussis Considerations
• Consider giving Tdap to pregnant women
at high-risk of pertussis exposure
– Health care providers
– Child care providers
– Caregiver of infant younger than 12 months
– Community has known pertussis activity
– Adolescents

Vaccines, Pregnancy and Breast-feeding

Pertussis Considerations
• Waiting until second trimester of
pregnancy to give Tdap is reasonable
precaution to minimize patients’ concerns
of risks
– Acellular pertussis is not-live
– Presumed safe in pregnancy
– However, patients may be concerned recalling whole
cell pertussis vaccine previously available

Vaccines, Pregnancy and Breast-feeding

Pertussis Considerations
• Passive immunity to pertussis (trans-
placental transfer of antibodies) from Tdap
may be insufficient to protect infant
• Theoretically, maternal Tdap could
interfere with neonatal pertussis vaccine
response
– No studies proving this occurs

Vaccines, Pregnancy and Breast-feeding

Tetanus-Diphtheria
and Pertussis
• Women with incomplete childhood series
– 2 doses of Td separated by 4 weeks
– Tdap postpartum 6 to 12 months after the
second Td dose

http://www.cdc.gov/vaccines/pubs/preg-guide.htm#19

Vaccines, Pregnancy and Breast-feeding

Tetanus-Diphtheria
and Pertussis
• If >2 years and <10 years since last Td
– Give Tdap immediately postpartum
• If >10 years since last Td and
“presumed sufficient” tetanus immunity
– Give Tdap immediately postpartum
• There is an increased risk of local
reactions if Tdap given <2 years from
previous Td
Vaccines, Pregnancy and Breast-feeding
Case Questions
6. Based on this information, are you going
to give your patient Td or Tdap?
– Tdap
7. When?
– Post-partum
8. Why?
– This patient is presumed to have sufficient
tetanus protection because she is younger than
31 years old, had a complete childhood series
and had a booster of Td at age 14.
Vaccines, Pregnancy and Breast-feeding
Recommended Vaccine
in Pregnancy
• Only one vaccine is in the Advisory
Committee on Immunization Practice’s
(ACIP’s) “recommended” category.
– Which is it?
• INFLUENZA

– Should this patient get it?

• YES

Vaccines, Pregnancy and Breast-feeding

Recommended Vaccination
• Influenza vaccine is RECOMMENDED
for women who are pregnant or may
become pregnant during flu season
– Seasonal influenza
– H1N1
– NOT THE LIVE-ATTENUATED
INFLUENZA VACCINE (nasal spray)

Vaccines, Pregnancy and Breast-feeding

According to Advisory Committee
on Immunization Practices (ACIP)
• Other vaccines “Should be considered
if otherwise indicated”
– Hepatitis B
– Meningococcal
– Rabies

Vaccines, Pregnancy and Breast-feeding

Hepatitis B
• Hepatitis B vaccine should be considered
for high-risk pregnant women
• Risk factors for Hepatitis B
– More than one sexual partner in the previous
6 months
– Current or past history of sexually transmitted
infection
– Recent or current injection drug use
– Having a Hepatitis B Ag-positive sex partner
Vaccines, Pregnancy and Breast-feeding
Meningococcal
• No data available
• Bacterial vaccine
presumed safe
• If a woman is pregnant at the time of
vaccination, a registry for pregnancy
outcome surveillance exists

Vaccines, Pregnancy and Breast-feeding

Human Papilloma Virus (HPV)
• Quadrivalent HPV (Gardasil®) is not
recommended for use in pregnancy
• If a quadrivalent HPV vaccine given,
delay remainder of series until after
delivery
• Bivalent HPV (Cervarix®) is category B
and may be used in pregnancy

Vaccines, Pregnancy and Breast-feeding

Rabies
• No indication of fetal
adverse effects to rabies vaccines
• 90-95% mortality to untreated rabies
• Pregnant women bitten by potentially
rabid animal should receive post-
exposure rabies prophylaxis

Vaccines, Pregnancy and Breast-feeding

Recommended to Avoid
• Live-attenuated viruses
– MMR
– Varicella (Varivax®)
– Zoster (Zostavax®)
– Vaccinia (Smallpox)
– Yellow Fever

Vaccines, Pregnancy and Breast-feeding

Recommended to Avoid
• Inactivated Polio
– Vaccination should be avoided on
theoretical grounds
– If a woman requires immediate protection
against polio, administer IPV according to
recommended schedules

Vaccines, Pregnancy and Breast-feeding

Yellow Fever
• Only if travel to an endemic area is
unavoidable
• Antigen appears to cross placenta in
low level, but no congenital anomalies
associated

Vaccines, Pregnancy and Breast-feeding

Breast-Feeding
• No vaccines affect breast-feeding safety
• Breast-feeding does not diminish
vaccines’ effectiveness
• Giving a vaccine during breast-feeding
theoretically may protect infant
• Any routine vaccine can be given
– (except smallpox)

Vaccines, Pregnancy and Breast-feeding

Summary
• Medical knowledge
– ACIP recommends influenza vaccine (both
seasonal and H1N1) during pregnancy
– No live-attenuated vaccines should be
administered to pregnant women (MMR,
varicella, nasal spray influenza)
– High-risk women should receive Hepatitis
B vaccine

Vaccines, Pregnancy and Breast-feeding

Summary
• Medical knowledge
– Bivalent HPV (Cervarix®) is category B and
may be given during pregnancy
– Quadrivalent HPV (Gardasil®) is currently
not approved for use during pregnancy

Vaccines, Pregnancy and Breast-feeding

Summary
• Patient care
– Tetanus-diphtheria (Td) should be up-to-date
(within 10 years) or booster should be given
– Delay Td and give Tdap immediately post-partum
if >10 years since last Td and “presumed
sufficient” tetanus immunity
– If Td series is incomplete, it should be updated
during pregnancy
– If >2 years but <10 years since last Td, give Tdap
(Tetanus-diphtheria and acellular pertussis)
immediately postpartum
Vaccines, Pregnancy and Breast-feeding
Summary
• Patient care
– Prenatal visits are an excellent time to assess
immunization status
– Update necessary vaccines at prenatal visits
• Interpersonal communication
– Physicians should discuss all immunization
risks and benefits, especially Tdap, with
patients
Vaccines, Pregnancy and Breast-feeding