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Vaccinations in Pregnancy DENISE K. SUR, M.D., and DAVID H.WALLIS, M.D., David Geffen School of Medicine, University of California—Los Angeles, California THEODORE X. O’CONNELL, M.D., Kaiser Permanente–Woodland Hills, Woodland Hills, California Adult immunization rates have fallen short of national goals partly because of mis- conceptions about the safety and benefits of current vaccines. The danger of these misconceptions is magnified during pregnancy, when concerned physicians are hesi- tant to administer vaccines and patients are reluctant to accept them. Routine vaccines that generally are safe to administer during pregnancy include diphtheria, tetanus, influenza, and hepatitis B. Other vaccines, such as meningococcal and rabies, may be considered. Vaccines that are contraindicated, because of the theoretic risk of fetal transmission, include measles, mumps, and rubella; varicella; and bacille Calmette- Guérin. A number of other vaccines have not yet been adequately studied; therefore, theoretic risks of vaccination must be weighed against the risks of the disease to mother and fetus. Inadvertent administration of any of these vaccinations, however, is not considered an indication for termination of the pregnancy. (Am Fam Physician 2003;68:E299-309. Copyright© 2003 American Academy of Family Physicians.) This article he administration of vaccines Vaccines commonly administered by family exemplifies the AAFP during pregnancy poses a num- physicians, and their indication for use during 2003 Annual Clinical ber of concerns to physicians and pregnancy, are summarized in Table 1.1 Focus on prevention and health promotion. patients about the risk of trans- Women of childbearing age often are con- mitting a virus to a developing cerned about whether breastfeeding is safe Tfetus. This risk is primarily theoretic. Live- during immunization. Physicians should reas- virus vaccines are therefore generally con- sure their patients that no vaccines are con- traindicated in pregnant women. According to traindicated during breastfeeding.1 the Centers for Disease Control and Preven- tion (CDC),1 if a live-virus vaccine is inadver- Tetanus and Diphtheria tently given to a pregnant woman, or if a The tetanus and diphtheria toxoids vaccine woman becomes pregnant within four weeks (Td) is effective in preventing tetanus and after vaccination, she should be counseled diphtheria, two potentially life-threatening about potential effects on the fetus. Inadver- conditions. Diphtheria is an infection of the tent administration of these vaccines, how- nasal, pharyngeal, laryngeal, or other mucous ever, is not considered an indication for termi- membranes that can cause neuritis, myo- nation of the pregnancy. carditis, thrombocytopenia, and ascending No evidence shows an increased risk from paralysis.2 Tetanus infection can cause pro- vaccinating pregnant women with inactivated duction of a neurotoxin, leading to tetanic virus or bacterial vaccines or toxoids.1 There- muscle contractions. fore, if a patient is at high risk of being Td toxoid is routinely recommended for exposed to a particular disease, if infection susceptible pregnant women. While no evi- would pose a risk to the mother or fetus, and dence exists to prove that tetanus and diph- if the vaccine is unlikely to cause harm, the theria toxoids are teratogenic,1 waiting until benefits of vaccinating a pregnant woman the second trimester of pregnancy to adminis- This electronic (E) ver- usually outweigh the potential risks. ter Td is a reasonable precaution, minimizing sion supplements the Physicians should consider vaccinating any concern about the theoretic possibility of print version of this pregnant women on the basis of the risks of such reactions.1 Previously vaccinated preg- article and addresses vaccinations typically vaccination versus the benefits of protection nant women who have not received a Td vac- not administered on in each particular situation, regardless of cination within the past 10 years should a routine basis. whether live or inactivated vaccines are used. receive a booster dose. Pregnant women who JULY 15, 2003 / VOLUME 68, NUMBER 2 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN E299 cent of influenza seasons).3 This recommen- Routine vaccinations that generally are safe during pregnancy dation is based on data from pandemics of include diphtheria, tetanus, influenza, and hepatitis B. 1918 and 1957, as well as limited studies done since then demonstrating that women in their second or third trimesters have higher mor- bidity, similar to other high-risk patients, are not immunized or only partially immu- from influenza infection.4 nized should complete the primary series.1 Immunization should be avoided in most patients during the first trimester to avoid a Influenza coincidental association with spontaneous Fever, malaise, myalgia, and upper respira- abortion, which is common in the first tory tract symptoms or infections characterize trimester. However, pregnant women with influenza infection. Most severe complica- medical conditions that increase their risk for tions are the result of pneumonia secondary complications from influenza (e.g., asthma, car- to influenza infection. There are three strains diovascular disease, diabetes, suppressed of influenza (A, B, and C), with types A and B immune system) should be vaccinated before responsible for epidemics in the United States. the influenza season regardless of the pregnancy The influenza vaccine is a killed virus trimester. Studies of influenza immunization preparation with an annually adjusted anti- with more than 2,000 pregnant women have genic makeup. It should be administered demonstrated no adverse fetal effects.1 annually between October and December to high-risk patients. The vaccine should be Hepatitis A administered to all pregnant women who will Hepatitis A infects approximately 100,000 be in the second or third trimester of preg- persons annually in the United States, of nancy during the influenza season (which which 100 die.5 It is acquired via the fecal-oral peaks from December to March in temperate route by person-to-person contact or inges- climates but may extend into May in 20 per- tion of contaminated food or water. TABLE 1 Immunizations During Pregnancy Considered safe if Contraindicated during Special recommendations pertain otherwise indicated pregnancy or safety Anthrax Tetanus and diphtheria not established Hepatitis A toxoids (Td) BCG* Japanese encephalitis Hepatitis B Measles* Pneumococcal Influenza Mumps* Polio (IPV) Meningococcal Rubella* Typhoid (parenteral and Ty21a*) Rabies Varicella* Vaccinia* Yellow fever* *—Live, attenuated vaccine. BCG = bacille Calmette-Guérin; IPV = inactivated polio virus. Adapted from Guidelines for vaccinating pregnant women. Recommendations of the Advisory Committee on Immunization Practices (ACIP). Atlanta, Ga.: Centers for Disease Control and Prevention, 2002. E300 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 68, NUMBER 2 / JULY 15, 2003 Vaccines in Pregnancy Hepatitis A vaccines are derived from tains noninfectious hepatitis B surface antigen viruses grown in diploid cell cultures and are particles and should cause no risk to the fetus, formalin inactivated.5 Safety of hepatitis A neither pregnancy nor lactation is a con- vaccination during pregnancy has not been traindication to vaccination.1 determined. Because hepatitis A vaccine is produced from inactivated virus, the risk to Pneumococcal the developing fetus is expected to be low. Streptococcus pneumoniae is a gram-positive Therefore, theoretic risks of vaccination diplococcal bacterium that is a major cause of should be weighed against the risk for pneumonia, meningitis, and bacteremia. Risk hepatitis A infection in pregnant women factors for pneumococcal infection in preg- who may be at risk for exposure. Examples nant women include diabetes, cardiovascular calling for immunization include travel to disease, asplenia, immunodeficiency, asthma, endemic areas or intravenous drug use dur- and other respiratory diseases. ing pregnancy.6 The current vaccine includes purified cap- Finally, if a pregnant woman is exposed to sular polysaccharide from the 23 most com- hepatitis A, administration of immune globu- mon types of S. pneumoniae. It is recom- lin is strongly recommended; this agent is mended by the CDC for use in adults with any considered safe during pregnancy and is more of the aforementioned risk factors.3 than 85 percent effective in preventing acute The Advisory Committee on Immunization hepatitis infection.3 Practices (ACIP) currently recommends that women at high risk be given this vaccination Hepatitis B before, but not during, pregnancy. The safety Hepatitis B infection is caused by a DNA- of the pneumococcal vaccine during preg- containing virus and is transmitted through nancy has not been evaluated, although no contact with infected blood, sexual activity, adverse consequences have been reported and sharing of intravenous needles. Hepatitis among newborns whose mothers were inad- B infection may be asymptomatic, or it may vertently vaccinated.1 result in fulminant hepatitis. The risk of developing chronic illness associ- Polio ated with complications of cirrhosis, hepato- Poliovirus is an enterovirus with three dif- cellular carcinoma, and a chronic carrier state ferent strains that cause disease. Exposure may has been a key factor in the recommendation result in asymptomatic infection as well as for universal vaccination of all children. Vacci- nonparalytic and paralytic disease.
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