CommitteeOpinion2017
Number 741, June 2018


Immunization, Infectious Disease, and Public Health Preparedness Expert Work Group
This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Immunization, Infectious Disease, and Public Health Preparedness Expert Work Group, in collaboration with member Kevin A. Ault, MD and Laura E. Riley, MD.

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Maternal Immunization

ABSTRACT: Immunization is an essential part of care for adults, including pregnant women. Influenza vaccination for pregnant women is especially important because pregnant women who contract influenza are at greater risk of maternal morbidity and mortality in addition to fetal morbidity, including congenital anomalies, spontaneous abortion, preterm birth, and low birth weight. Other vaccines provide maternal protection from severe morbidity related to specific pathogens such as pneumococcus, meningococcus, and hepatitis for at-risk pregnant women. Obstetrician–gynecologists and other obstetric care providers should routinely assess their pregnant patients’ vaccination status. Based on this assessment they should recommend and, when possible, administer needed vaccines to their pregnant patients. There is no evidence of adverse fetal effects from vaccinating pregnant women with inactivated virus, bacterial vaccines, or toxoids, and a growing body of data demonstrate the safety of such use. Women who are or will be pregnant during influenza season should receive an annual influenza vaccine. All pregnant women should receive a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine during each pregnancy, as early in the 27–36-weeks-of-gestation window as possible.


Recommendations

The American College of Obstetricians and Gynecologists makes the following recommendations:

  • Obstetrician–gynecologists and other obstetric care providers should routinely assess their pregnant patients’ vaccination status.
  • Obstetrician–gynecologists and other obstetric care providers should recommend and, when possible, administer needed vaccines to their pregnant patients.
  • Women who are or will be pregnant during influenza season should receive an annual influenza vaccine.
  • All pregnant women should receive a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine during each pregnancy, as early in the 27–36-weeks-of-gestation window as possible.
  • Other vaccines may be recommended during pregnancy depending on the patient’s age, prior immunizations, comorbidities, or disease risk factors. 

Background

Immunization is an essential part of care for adults, including pregnant women. Influenza vaccination for pregnant women is especially important because pregnant women are at greater risk of maternal morbidity and mortality in addition to fetal morbidity, including congenital anomalies, spontaneous abortion, preterm birth, and low birth weight (1). Vaccines such as Tdap provide fetal and neonatal benefit through passive transfer of protective antibodies across the placenta. Other vaccines provide maternal protection from severe morbidity related to specific pathogens such as pneumococcus, meningococcus, and hepatitis for at-risk pregnant women. There is no evidence of adverse fetal effects from vaccinating pregnant women with inactivated virus, bacterial vaccines, or toxoids, and a growing body of data demonstrate the safety of such use (2, 3). Therefore, all pregnant women should receive an influenza vaccination during influenza season and Tdap with each pregnancy. Additional vaccines are indicated during pregnancy for women with certain conditions, as noted in this document. Other vaccines should be reserved for use in the postpartum period.

The Ob-Gyn Role

Obstetrician–gynecologists and other obstetric care providers play a critical role in ensuring pregnant women receive recommended vaccines. Studies consistently demonstrate that when the recommendation and availability of vaccination during pregnancy comes directly from a woman’s obstetrician or other obstetric care provider, the odds of vaccine acceptance and receipt are 5-fold to 50-fold higher (4–8). As such, obstetrician–gynecologists and other obstetric care providers should routinely assess their pregnant patients’ vaccination status. Based on this assessment they should recommend and, when possible, administer needed vaccines to their pregnant patients. Table 1 provides an easy-to-use reference to quickly assess which vaccines a pregnant woman needs and when she should receive those vaccines (note: Table 1 can be reproduced free of charge). Women who are or will be pregnant during influenza season should receive an annual influenza vaccine. Any of the licensed, recommended, age-appropriate inactivated influenza vaccines can safely be given during any trimester (7). All pregnant women should receive a Tdap vaccine during each pregnancy, as early in the 27–36-weeks-of-gestation window as possible (2). Other vaccines may be recommended during pregnancy depending on a patient’s age, prior immunizations, comorbidities, or disease risk factors (Table 1).

Table 1 summarizes recommended immunizations during pregnancy based on the Centers for Disease Control and Prevention’s (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States and Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, United States (9, 10). In addition to Tdap and influenza vaccines, this table outlines the additional recommended vaccines to protect pregnant women who have either high-risk conditions or practices that place them at greater risk of acquisition of these vaccine-preventable diseases. After evaluating your patient’s immunization history and medical and social histories, determine if your patients are appropriate candidates for other vaccines noted in Table 1. Vaccines that may be required for travel are not included here. For information on travel vaccines during pregnancy, see https://wwwnc.cdc.gov/travel/.

Table 1. Summary of Maternal Immunization Recommendations

For More Information

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for obstetrician–gynecologists, other health care providers, and patients. You may view these resources at: www.acog.org/More-Info/MaternalImmunization.

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s website, or the content of the resource. The resources may change without notice.

References

  1. Omer SB. Maternal immunization. N Engl J Med 2017;376:1256–67.
  2. Update on immunization and pregnancy: tetanus, diphtheria, and pertussis vaccination. Committee Opinion No. 718. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e153–7.
  3. Polyzos KA, Konstantelias AA, Pitsa CE, Falagas ME. Maternal influenza vaccination and risk for congenital malformations: a systematic review and meta-analysis. Obstet Gynecol 2015;126:1075–84.
  4. Swamy GK, Heine RP. Vaccinations for pregnant women. Obstet Gynecol 2015;125:212–26.
  5. Centers for Disease Control and Prevention. Flu vaccination coverage among pregnant women–United States, 2015–16 flu season. Atlanta (GA): CDC; 2016.
  6. Ahluwalia IB, Jamieson DJ, Rasmussen SA, D'Angelo D, Goodman D, Kim H. Correlates of seasonal influenza vaccine coverage among pregnant women in Georgia and Rhode Island. Obstet Gynecol 2010;116:949–55.
  7. Influenza vaccination during pregnancy. Committee Opinion No. 732. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e109–14.
  8. Shavell VI, Moniz MH, Gonik B, Beigi RH. Influenza immunization in pregnancy: overcoming patient and health care provider barriers. Am J Obstet Gynecol 2012;207(3 suppl):S67–74.
  9. Kim DK, Riley LE, Hunter P. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2018. MMWR Morb Mortal Wkly Rep 2018;67:158–60.
  10. Robinson CL, Romero JR, Kempe A, Pellegrini C, Szilagyi P. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, United States, 2018. MMWR Morb Mortal Wkly Rep 2018;67:156–7. 

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Maternal immunization. ACOG Committee Opinion No. 741. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e214–7.

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