Committee Opinion. Immunization During Pregnancy. Committee on Obstetric Practice. Number 282, January 2003

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1 ACOG Committee on Obstetric Practice Committee Opinion This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Copyright January 2003 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Requests for authorization to make photocopies should be directed to: Copyright Clearance Center 222 Rosewood Drive Danvers, MA (978) ISSN X The American College of Obstetricians and Gynecologists th Street, SW PO Box Washington, DC /76543 Immunization during pregnancy. ACOG Committee Opinion No American College of Obstetricians and Gynecologists. Obstet Gynecol 2003; 101: Number 282, January 2003 Immunization During Pregnancy ABSTRACT: Preconceptional immunization of pregnant women to prevent disease in the offspring, when practical, is preferred to vaccination of pregnant women. The benefits of immunization to the pregnant woman and her neonate usually outweigh the theoretic risks of adverse effects. Current information on the safety of vaccines given during pregnancy is subject to change and can be verified from the Centers for Disease Control and Prevention web site at The benefits of immunization to the pregnant woman and her neonate usually outweigh the theoretic risks of adverse effects. The theoretic risks of the vaccination of pregnant women with killed virus vaccines have not been identified. Current recommendations for immunization of pregnant women are presented in Table 1. Although new information continues to confirm the safety of vaccines intentionally or inadvertently given during pregnancy, current information is subject to change because the effects of many diseases and vaccines on the pregnant woman or the fetus may be rare and infrequently reported. (For further information and updates refer to In the decision of whether to immunize a pregnant woman with other vaccines not listed in Table 1, the risk for exposure to disease and its deleterious effects on the pregnant woman and the fetus must be balanced against the efficacy of the vaccine and any beneficial effects resulting from it. Preconceptional immunization of women to prevent disease in the offspring, when practical, is preferred to vaccination of pregnant women with certain vaccines. Vaccination of women during the postpartum period, especially for rubella and varicella, should be encouraged. Women susceptible to rubella should be vaccinated with measles mumps rubella on postpartum discharge from the hospital.

2 Table 1. Immunization During Pregnancy Risk from Risk from Risk from Indications for Disease to Disease to Type of Immunizing Immunization Immunobiologic Pregnant Fetus or Immunizing Agent to During Dose Agent Woman Neonate Agent Fetus Pregnancy Schedule* Comments LIVE VIRUS VACCINES Measles Significant Significant Live None Contraindicated Single dose Vaccination of morbidity, low increase in attenuated confirmed (see immune SC, preferably as susceptible women mortality; not abortion rate; virus vaccine globulins) measles mumps should be part of altered by may cause rubella postpartum care. pregnancy malformations Breastfeeding is not a contraindication. Mumps Low morbidity Possible Live attenuated None Contraindicated Single dose SC, Vaccination of and mortality; increased rate virus vaccine confirmed preferably as susceptible women not altered of abortion in measles mumps should be part of by pregnancy first trimester rubella postpartum care Poliomyelitis No increased Anoxic fetal Live attenuated None Not routinely Primary: Two doses Vaccine indicated for incidence in damage virus (oral confirmed recommended for of enhanced-potency susceptible pregnant pregnancy, but reported; 50% polio vaccine) women in the inactivated virus SC women traveling in may be more mortality in and enhanced- United States, at 4 8 week intervals endemic areas or severe if it does neonatal potency inacti- except women and a third dose in other high-risk occur disease vated virus at increased risk 6 12 months after situations vaccine of exposure the second dose Immediate protection: One dose oral polio vaccine (in outbreak setting) Rubella Low morbidity High rate of Live attenuated None Contraindicated, Single dose SC, Teratogenicity of and mortality; abortion and virus vaccine confirmed but congenital preferably as vaccine is theoretic, not altered by congenital rubella syndrome measles mumps not confirmed to pregnancy rubella syndrome has never been rubella date; vaccination of described after susceptible women vaccine should be part of postpartum care Yellow fever Significant Unknown Live attenuated Unknown Contraindicated Single dose SC Postponement of morbidity and virus vaccine except if exposure travel preferable mortality; not is unavoidable to vaccination, if altered by possible pregnancy

3 Varicella Possible Can cause Live attenuated None Contraindicated, Two doses needed Teratogenicity of increase congenital virus vaccine confirmed but no adverse with second dose vaccine is theoretic, in severe varicella in 2% outcomes reported given 4 8 weeks outcomes reported pneumonia of fetuses if given in after first dose. weeks 4 8 not infected during pregnancy Should be strongly confirmed to date. the second encouraged Vaccination of trimester susceptible women should be considered postpartum OTHER Influenza Increase in Possible Inactivated virus None All women One dose IM morbidity and increased vaccine confirmed who are pregnant every year mortality abortion rate; in the second during no malformations and third epidemic of confirmed trimester during new antigenic the flu season strain (October March); women at high risk for pulmonary complications regardless of trimester Rabies Near 100% Determined by Killed virus Unknown Indications for Public health authorities fatality; not maternal disease vaccine prophylaxis not to be consulted for altered by altered by indications, dosage, pregnancy pregnancy; each and route of case considered administration individually Hepatitis B Possible Possible increase Purified surface None reported Pre-exposure and Three-dose series IM Used with hepatitis B increased in abortion rate antigen produced postexposure for at 0, 1, and 6 months immune globulin for severity during and preterm birth; by recombinant women at risk of some exposures; third trimester neonatal hepatitis technology infection exposed newborn can occur; high needs birth dose risk of newborn vaccination and carrier state immune globulin as soon as possible. All infants should receive birth dose of vaccine. Hepatitis A No increased Inactivated virus None reported Pre-exposure and Two-dose schedule risk during postexposure 6 months apart pregnancy for women at risk of infection; international travelers

4 INACTIVATED BACTERIAL VACCINES Pneumococcus No increased Unknown, but Polyvalent None reported Recommended In adults, one SC or IM risk during depends on polysaccharide for women with dose only; consider pregnancy; maternal illness vaccine asplenia; metabolic, repeat dose in 6 years no increase in renal, cardiac, for high-risk women severity of pulmonary diseases; disease smokers; immunosuppressed. Indications not altered by pregnancy. Meningococcus Significant Unknown, but Quadrivalent None reported Indications One SC dose; public morbidity and depends on polysaccharide not altered by health authorities mortality; not maternal illness vaccine pregnancy; consulted altered by vaccination pregnancy recommended in unusual outbreak situations Typhoid Significant Unknown Killed or live None confirmed Not recommended Killed Oral vaccine preferred morbidity and attenuated oral routinely except for Primary: Two mortality; not bacterial vaccine close, continued injections SC at altered by exposure or travel least 4 weeks apart. pregnancy to endemic areas Booster: Single dose SC or ID (depending on type of product) Booster: Schedule not yet determined Anthrax Significant Unknown, but Preparation from None confirmed Not routinely Six-dose primary Teratogenicity of morbidity and depends on cell-free filtrate recommended vaccination SC, then vaccine theoretical mortality; not maternal illness of B anthracis; unless pregnant annual booster altered by no dead or live women work vaccination pregnancy bacteria directly with B anthracis, imported animal hides, potentially infected animals in high incidence areas (not United States) or military personnel deployed to high-risk exposure areas (continued)

5 Table 1. Immunization During Pregnancy (continued) Risk from Risk from Risk from Indications for Disease to Disease to Type of Immunizing Immunization Immunobiologic Pregnant Fetus or Immunizing Agent to During Dose Agent Woman Neonate Agent Fetus Pregnancy Schedule* Comments TOXOIDS Tetanus Severe Neonatal Combined None confirmed Lack of primary Primary: Two doses Updating of immune diphtheria morbidity; tetanus tetanus series, or no IM at 1 2-month status should be part tetanus mortality 60% diphtheria booster within interval with a third of antepartum care mortality 30%; toxoids preferred: past 10 years dose 6 12 months diphtheria adult tetanus after the second. mortality 10%; diphtheria Booster: Single dose unaltered by formulation IM every 10 years pregnancy after completion of primary series SPECIFIC IMMUNE GLOBULINS Hepatitis B Possible Possible Hepatitis B None reported Postexposure Depends on exposure; Usually given with increased increase in immune prophylaxis consult Immunization hepatitis B virus severity during abortion rate globulin Practices Advisory vaccine; exposed third trimester and preterm committee recommen- newborn needs birth; neonatal dations (IM) immediate postexpohepatitis can sure prophylaxis occur; high risk of carriage in newborn Rabies Near 100% Determined by Rabies immune None reported Postexposure Half dose at injury site, Used in conjunction fatality; not maternal disease globulin prophylaxis half dose in deltoid with rabies killed virus altered by vaccine pregnancy Tetanus Severe morbidity; Neonatal tetanus Tetanus immune None reported Postexposure One dose IM Used in conjunction mortality 60% mortality 60% globulin prophylaxis with tetanus toxoid

6 Varicella Possible Can cause Varicella zoster None reported Should be One dose IM within Indicated also for increase in congenital immune globulin considered for 96 hours of exposure newborns of women severe varicella varicella with (obtained from healthy pregnant who developed varicella pneumonia increased the American women exposed to within 4 days before mortality in neo- Red Cross) varicella to protect delivery or 2 days natal period; against maternal, following delivery; very rarely not congenital, approximately 90 95% causes con- infection of adults are immune to genital defects varicella; not indicated for prevention of congenital varicella STANDARD IMMUNE GLOBULINS Hepatitis A Possible Probable in- Standard None reported Postexposure 0.02 ml/kg IM in one Immune globulin should increased crease in immune prophylaxis, but dose of immune be given as soon as severity dur- abortion rate globulin hepatitis A virus globulin possible and within ing third and preterm vaccine should 2 weeks of exposure; trimester birth; possible be used with infants born to women transmission to hepatitis A who are incubating the neonate at deliv- immune globulin virus or are acutely ill at ery if woman is delivery should receive incubating the one dose of 0.5 ml as virus or is acutely soon as possible after ill at that time birth *Abbreviations: ID, intradermally; IM, intramuscularly; PO, orally; and SC, subcutaneously. Two doses necessary for adequate vaccination of students entering institutions of higher education, newly hired medical personnel, and international travelers. Inactivated polio vaccine recommended for nonimmunized adults at increased risk. Data from General recommendations on immunization. Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP). Centers for Disease Control. MMWR Recomm Rep;51(RR-2):1 35. Available at Retrieved October 11, 2002.