Contributor: MFM Division
Last Update: 9/4/2012
The four major types of immunization agents are:
- Immune Globulin Preparations – A protein fraction of animal or donor plasma that causes rapid, but transient, elevation in antibody titers to prevent or reduce the severity of disease. Generally, these can be safely used during pregnancy.
- Live Vaccines – Bacterial or viral vaccines which contain less virulent strains of the selected microorganism. Generally, these are contraindicated during pregnancy because of the theoretic risk to the developing fetus.
- Killed Vaccines – Whole or partial viruses or bacteria inactivated chemically or thermally.
- Toxoids – Bacterial exotoxins which are rendered non-toxigenic by chemical treatment.
There is no known evidence of risk to the fetus from live or inactivated vaccines or toxoids. However, live vaccines pose a theoretical risk and data on immunization in pregnancy is limited. Ideally, women should be vaccinated against preventable diseases as recommended by the CDC prior to pregnancy. Several situations warrant vaccination of the pregnant patient such as travel to an area where the disease is endemic, possibility of exposure during an epidemic, or accidental exposure to a potentially fatal disease. It is impossible to assess an accurate risk to the fetus from an immunizing agent. Each case should be individualized by determining: 1) the maternal susceptibility to the disease, 2) the risk of exposure and 3) the risk of disease. Generally, inadvertent vaccination of a pregnant patient is not an indication for termination.
The CDC places immunization agents in pregnancy into three categories:
· Routine/Consider if otherwise indicated- Vaccine is recommended in pregnancy for women who meet the age requirements and who lack evidence of immunity (e.g. lack documentation of vaccination or have no evidence of prior infection).
· Conditional recommendation- Vaccine is recommended in pregnancy for women who have risk factors such as medical, occupational, or lifestyle indications.
The following are guidelines for immunization during pregnancy:
I. IMMUNE GLOBULINS
Immune globulins are all safely used during pregnancy and routine administration should be considered if otherwise indicated.
A. Pooled Human IG
- Hepatitis A – Routine indication for post-exposure prophylaxis. May be used for pre-exposure prophylaxis prior to travel to endemic areas.
- Measles – Routine indication for post-exposure prophylaxis. Can prevent or modify disease in susceptible individuals if given within six days of exposure.
B. Hyperimmune IG
- Hepatitis B –Routine indication for post-exposure prophylaxis.
- Rabies – Routine indication for post-exposure prophylaxis.
- Tetanus – Routine indication for post-exposure prophylaxis in those whose toxoid immune status is uncertain or incomplete.
- Varicella -zoster immune globulin- Routine indication for post-exposure prophylaxis in pregnancy. It may ameliorate maternal severity of chicken pox in susceptible individuals if administered within 96 hours of exposure. Not commercially available at this time.
C. Horse Serum IG – Increased risk of anaphylactic reaction
- Botulism – Not commercially available but may be available through consultation with the CDC. Indicated for treatment of infection only for infants <1 year. Not indicated for adult infection
- Diphtheria – Not commercially available but may be available through consultation with the CDC.
II. LIVE VACCINES
Live vaccines generally should be avoided during pregnancy (see exceptions below). Second or third trimester immunization is preferable because of the theoretic risk of first trimester exposure. The pregnancy interval after receiving preconception live vaccines should be at least one month. Live vaccines should not be given to HIV+ patients with CD4 T- cell counts < 200 cells/microL Vaccination of susceptible women should be a routine part of post partum care.
- Poliomyelitis (e-IPV) – Conditional recommendation for immediate protection during an outbreak for previously nonimmunized individuals or for travel to endemic areas when plans cannot be delayed. Risk of paralysis in adults increased.
- Yellow Fever – Conditional recommendation for travel to endemic areas where exposure is unavoidable. If exposure is avoidable and vaccination only necessary for international travel, a “Letter of Waiver” may be an option.
- Measles – Contraindicated during pregnancy. Postpone conception one month post-immunization.
- Mumps – Contraindicated during pregnancy. Postpone conception one month post immunization.
- Rubella – Contraindicated during pregnancy. Postpone conception one month post immunization.
- Chicken pox – Contraindicated during pregnancy. Postpone conception one month post immunization.
- Smallpox – Disease eradicated in 1980. Vaccination neither indicated nor available for general use.
- Bacillus Calmette – Guerin (BCG) –Contraindicated in pregnancy. Efficacy of use against TB uncertain in adults.
III. KILLED (INACTIVATED) VACCINES
- Hepatitis B – Conditional recommendation during pregnancy for pre- and post-exposure or for individuals at high risk (i.e. house hold contact with HBV, health care workers, injection drug use, sexually transmitted infections including HIV+, dialysis patients, chronic liver disease, international travelers, etc.). Women who initiated the vaccine series may complete it in pregnancy.
- Hepatitis A – Conditional recommendation during pregnancy for women traveling to or working in countries with high or intermediate endemicity of hepatitis A, which use illegal drugs, work with hepatitis A infected primates or with hepatitis A virus in a laboratory setting, or have chronic liver disease or clotting factor disorders.
- Influenza – Routine recommendation of the inactivated parenteral vaccine for all pregnant women during flu season (October-April) regardless of their stage of pregnancy. The intranasal vaccine is a live attenuated vaccine and is contraindicated in pregnancy.
- Rabies – Conditional recommendation during pregnancy for exposure to potentially rabid animals.
- HPV-Contraindicated in pregnancy. If a woman is found to be pregnant after the series is initiated, the remainder of the regimen should be administered after the completion of the pregnancy
- Cholera – Conditional recommendation in pregnancy for high risk of exposure or if travel to endemic area is unavoidable.
- Meningococcus – Conditional recommendation for high risk groups (11-18 year olds, women living in close quarters such as dorm rooms or the military, splenic dysfunction, immune deficiency, lab workers, travel to endemic areas, etc.)
- Plague – Conditional recommendation for laboratory workers and travel to endemic areas.
- Pneumococcus – Conditional recommendation during pregnancy for high risk individuals (cardiopulmonary disease, homozygous sickle cell disease, HIV+, splenic dysfunction, etc.).
- Hemophilus influenza – Conditional recommendation during pregnancy for high risk individuals (cardiopulmonary disease, homozygous sickle cell disease, HIV+, splenic dysfunction, etc.)
- Pertussis – The Tdap vaccine can be administered in the second and third trimesters of pregnancy but post partum administration is preferred. Administration of pertussis in pregnancy may decrease the infant’s immunogenic response to the pertussis vaccine.
- Typhoid- Conditional recommendation for pregnant women with close continued exposure or if travel to endemic areas is unavoidable. (Administer the inactive parenteral vaccine. The live attenuated oral vaccine should not be used in pregnancy.)
- Tetanus/Diphtheria – Routine recommendation in pregnancy as primary immunization, booster, or post exposure prophylaxis. The Td booster is recommended if > 10 years have elapsed since the last booster. The preferred schedule in pregnancy for unimmunized women is 2 doses of Td 4 weeks apart with Tdap postpartum. The Tdap vaccine can be administered in the second and third trimesters of pregnancy but post partum administration is preferred.
- Anthrax – Conditional recommendation for pregnant women with direct exposure to B. anthracic, imported animal hides, potentially infected animals, and military personnel deployed to high risk areas.
- Botulism- available through the CDC, use in pregnancy is unknown
V. OTHER VACCINES
There exist other vaccines such as adenovirus, CMV, and rotavirus which are not routinely available to the general population or whose efficacy has not been proven. Information regarding pregnancy and their administration is scant and no recommendation for their use can be made.
- CDC. Recommended Adult Immunization Schedule— United States, October 2007–September 2008. MMWR 2007;56:Q1–Q4.
- CDC. Guidelines for Vaccinating Pregnant Women- ACIP: Guidance for Vaccine Recommendations for Pregnant and Breast Feeding Women. May 5, 2008 Available at: https://www.cdc.gov/
- Immunization during pregnancy. ACOG Committee Opinion No. 282, American College of Obstetricians and Gynecologists. Obst Gynecol 2003 101: 201-12.