COVID-19 Vaccination Considerations for Obstetric–Gynecologic Care

Key Recommendations

• ACOG endorses the Centers for Disease Control and Prevention (CDC) recommendation that all eligible persons aged 6 months and older, including pregnant and lactating individuals, receive an updated 2024–2025 COVID-19 vaccine.
• ACOG recommends that all clinicians provide strong recommendation for COVID-19 vaccination to their pregnant and lactating patients.
• Vaccination may occur in any trimester, and emphasis should be on vaccine receipt as soon as possible to maximize maternal and fetal health.
• COVID-19 vaccines may be administered simultaneously with other vaccines. This includes vaccines routinely recommended during pregnancy, such as influenza, respiratory syncytial virus (RSV), and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap).
• For patients who do not receive any COVID-19 vaccine, the discussion should be documented in the patient’s medical record. During subsequent office visits, obstetrician–gynecologists should address ongoing questions and concerns and offer vaccination again.
• Obstetrician–gynecologists and other health care practitioners should lead by example by being vaccinated and encouraging eligible patients to be vaccinated as well.

COVID-19 Vaccine Information

At the time of this publication, three COVID-19 vaccines are currently either licensed or authorized under an Emergency Use Authorization (EUA) by the U.S. Food and Drug Administration (FDA) (Panagiotakopoulos MMWR 2024):

• Pfizer-BioNTech COVID-19 Vaccine/COMIRNATY
• Moderna COVID-19 Vaccine/SPIKEVAX
• Novavax COVID-19 Vaccine, Adjuvanted

COVID-19 vaccination is recommended for everyone aged 6 months and older, including pregnant people, for the prevention of COVID-19. There is no preferential recommendation for the use of any one COVID-19 vaccine over another.

All persons aged 12 years and older who receive an updated 2024–2025 COVID-19 vaccine are considered up to date with vaccination. Please refer to CDC COVID-19 vaccine guidance for information about being up to date in select populations.

COVID-19 vaccine recommendations are likely to be updated annually, and ACOG will strive to update this guidance as quickly as possible while maintaining accurate, evidence-based information.

Efficacy of Available COVID-19 Vaccines

All currently available COVID-19 vaccines are highly effective against moderate to severe COVID-19 disease. Furthermore, the data support the benefit of vaccination in reducing pregnancy complications, such as severe maternal morbidity, preterm birth, and stillbirth (Badell 2022). Infants born to vaccinated birthing people are at 50–80% reduced risk of COVID-19-related hospitalization for up to 6 months of age (Halasa 2022, Villar 2023). Finally, data suggest the benefit of vaccination in protecting against post-acute sequelae of SARS-CoV-2 infection (PASC; also referred to as long COVID) (Marra 2023).

Safety of Available COVID-19 Vaccines

Side Effects

Overall, the data support that COVID-19 vaccination can safely be administered to pregnant and lactating people.

Patients can be counseled that side effects after vaccination include injection site pain, headache, fatigue, and fever, and that the rates of these side effects are not higher in pregnant individuals (Shimabukuro 2021). Allergic reactions, including anaphylaxis, are rare following COVID-19 vaccination in nonpregnant individuals (ACIP August 2021). Guillain–Barré syndrome (GBS) has been reported after mRNA COVID-19 vaccines; however, a clear association between COVID-19 mRNA vaccination and GBS has not been demonstrated (Abara 2023).

Patients should be counseled about more severe side effects and when to seek medical care. For more information and details on side effects, see Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States from the CDC.

Pregnancy Surveillance Data

Post-approval surveillance is currently ongoing through CDC’s Vaccine Safety Datalink (VSD) and through the CDC and FDA’s Vaccine Adverse Event Reporting System (VAERS), a national early-warning system to detect possible safety problems in U.S.-licensed vaccines. Data from the VSD and VAERS demonstrate reassuring data regarding the safety of COVID-19 vaccines during pregnancy.

COVID-19 mRNA vaccination is not associated with an increased risk of pregnancy loss, such as stillbirth or miscarriage (Kharbanda 2021, Shimabukuro 2021, Zauche 2021). COVID-19 vaccination during pregnancy is also not associated with preterm birth or small-for-gestational age at birth overall (Lipkind 2022). COVID-19 mRNA vaccination during the first trimester is not associated with an increased risk of congenital anomalies (Ruderman 2022).

A recent systematic review and meta-analysis that included 61 clinical and preclinical studies involving pregnant persons (n=17,719,495) found no safety concerns regarding the administration of COVID-19 vaccines to pregnant individuals (Ciapponi 2023).

Health care professionals are encouraged to report any clinically significant adverse events after vaccination to VAERS, even if they are not sure if vaccination caused the event. In addition, we are anticipating that the following adverse events will be required to be reported to VAERS for COVID-19 vaccines administered under an EUA:

• Vaccine administration errors (whether associated with an adverse event or not)
• Serious adverse events (irrespective of attribution to vaccination) (such as death, life-threatening adverse event, inpatient hospitalization)
• Multisystem inflammatory syndrome in children (if vaccine is authorized in children) or adults
• Cases of COVID-19 that result in hospitalization or death

Other Considerations

• Locations administering COVID-19 vaccines should adhere to CDC guidance for the use of COVID-19 vaccines, including screening recipients for contraindications and precautions, having the necessary supplies available to manage anaphylaxis, implementing the recommended postvaccination observation periods, and immediately treating suspected cases of anaphylaxis with intramuscular injection of epinephrine.
• Vaccination should still be offered to individuals with a history of prior symptomatic or asymptomatic SARS-CoV-2 infection, including to people with PASC/long COVID and to people who experienced SARS-CoV-2 infection after vaccination.
• Vaccination in individuals who currently have SARS-CoV-2 infection can be deferred until the person has recovered from their acute illness and until criteria to discontinue from isolation have been met.

Obstetric Care Recommendations and Considerations

Pregnant Individuals

COVID-19 Infection Risk in Pregnancy

Pregnant and recently pregnant patients with COVID-19 are at increased risk of more severe illness compared with nonpregnant peers (Ellington MMWR 2020, Khan 2021). Available data indicate an increased risk of intensive care unit admission, need for mechanical ventilation and ventilatory support (extracorporeal membrane oxygenation), and death reported in pregnant women with symptomatic COVID-19 infection, when compared with symptomatic nonpregnant women (Zambrano MMWR 2020, Khan 2021). Pregnant and recently pregnant patients with comorbidities such as obesity and diabetes may be at an even higher risk of severe illness, consistent with the general population with similar comorbidities (Allotey 2020, Galang 2021).

COVID-19 Vaccination

ACOG strongly recommends that pregnant individuals be vaccinated against COVID-19. Given the potential for severe illness and death during pregnancy, as well as the increased risk for infection-related adverse pregnancy outcomes, vaccination is an important strategy for improving the overall health and well-being of the pregnant person and their infant.

Obstetrician–gynecologists and other obstetric care professionals should routinely assess their pregnant patients' vaccination status. On the basis of this assessment, they should recommend needed vaccines to their pregnant patients.

COVID-19 Vaccine Counseling

Individuals should have access to available information about the safety and efficacy of the vaccine. A conversation between the patient and their clinical team may assist with decisions regarding COVID-19 vaccination during pregnancy.

When recommending the COVID-19 vaccine, clinicians should review the available data on the risks and benefits of vaccination with pregnant patients, including the risks of not getting vaccinated in the context of the individual patient’s current health status and risk of exposure, including the possibility for exposure at work or home and the possibility for exposing high-risk household members. Conversations about risk should take into account the individual patient’s values and perceived risk of various outcomes and should respect and support autonomous decision making (ACOG 2013).

Any of the currently authorized COVID-19 vaccines can be administered to pregnant, recently pregnant, or lactating people.

Additional Vaccination Considerations for Pregnant Individuals

• Similar to their nonpregnant peers, vaccination of pregnant individuals with a COVID-19 vaccine may occur in any setting authorized to administer these vaccines. This includes any clinical setting and nonclinical community-based vaccination sites such as schools, community centers, and other mass vaccination locations.
• Pregnant individuals who experience fever after vaccination should be counseled to take acetaminophen. Acetaminophen has been proven to be safe for use in pregnancy and does not appear to impact antibody response to COVID-19 vaccines.
• COVID-19 vaccines may be administered simultaneously with other vaccines, such as influenza, RSV, and Tdap, or immunization products, such as anti-D immunoglobulin (eg, RhoGam).
• For patients who do not receive a COVID-19 vaccine, the discussion should be documented in the patient’s medical record. During subsequent office visits, obstetrician–gynecologists should address ongoing questions and concerns and offer vaccination again. Clinicians should reinforce the importance of other prevention measures such as hand washing, physical distancing, and wearing a mask.

Lactating Individuals

The American College of Obstetricians and Gynecologists strongly recommends that lactating individuals be vaccinated against COVID-19. While lactating individuals were not included in most clinical trials, COVID-19 vaccines should not be withheld from lactating individuals who otherwise meet the criteria for vaccination. Theoretical concerns regarding the safety of vaccinating lactating individuals do not outweigh the potential benefits of receiving the vaccine, and a growing body of evidence demonstrates that COVID-19 vaccination is safe during lactation (Bertrand 2021, Kachikis 2021). Furthermore, current data demonstrate that lactating people who have received mRNA COVID-19 vaccines have antibodies in their breast milk, suggesting a potential protective effect against infection in the infant, although the degree of clinical benefit is not yet known (Perl 2021, Young 2022). There is no need to avoid initiation or discontinue breastfeeding in patients who receive a COVID-19 vaccine (ABM 2020).

Information for pregnant and lactating patients can be found on ACOG’s patient website: COVID-19, Pregnancy, Childbirth, and Breastfeeding: Answers From Ob-Gyns.

Gynecologic Care Recommendations and Considerations

Individuals Contemplating Pregnancy

COVID-19 vaccination is strongly recommended for all individuals aged 6 months and older. Furthermore, ACOG recommends vaccination for individuals who are actively trying to become pregnant or are contemplating pregnancy. Additionally, it is not necessary to delay pregnancy after completing all recommended doses of the COVID-19 vaccine.

Claims linking COVID-19 vaccines to infertility are unfounded and have no scientific evidence supporting them. Given the mechanism of action and the safety profile of the mRNA vaccines in nonpregnant individuals, COVID-19 mRNA vaccines are not a cause of infertility. Because it does not replicate in the cells, the vaccine cannot cause infection or alter the DNA of a vaccine recipient and is also not a cause of infertility (Evans 2021, Morris 2021). Additionally, a growing body of data demonstrates that COVID-19 vaccines do not negatively impact fertility (Aharon 2022, Wesselink 2022, Chamani 2024). Therefore, ACOG recommends vaccination for all eligible people who may consider future pregnancy.

Finally, routine pregnancy testing is not recommended and should not be required before receiving any EUA-authorized or FDA-approved COVID-19 vaccine.

Routine Mammography

Reports of some patients developing temporary contralateral or ipsilateral lymphadenopathy after a COVID-19 vaccination have raised concerns about the possible effect on the interpretation of mammogram screening results. A Radiology Expert Scientific Panel has issued a recommendation that mammograms should be conducted before COVID-19 vaccination or postponed, if possible, for 4–6 weeks after the second vaccine dose to avoid uncertainty in the interpretation of mammogram results.

Screening mammograms are an essential part of preventive care, so postponing screening should only be considered when it does not unduly delay care. If a mammogram is performed fewer than 4–6 weeks after COVID-19 vaccination, patients should inform the mammogram technologist or radiologist when the vaccine was administered, which vaccine was received, and in which arm, to aid in the interpretation of screening results.

Reports of Post-Vaccination Menstrual Changes

There have been anecdotal reports of temporary changes in menstruation patterns (eg, heavier menses, early or late onset, and dysmenorrhea) in individuals who have recently been vaccinated for COVID-19. While environmental stresses can temporarily impact menses, vaccines have not been previously associated with menstrual changes. Studies have found that any effect of the COVID-19 vaccines on menstruation is minimal and temporary and should not be a reason for individuals to avoid vaccination (Edelman 2022, Darney 2023). The American College of Obstetricians and Gynecologists will continue to monitor and evaluate the available evidence on this issue.

Additionally, there is no reason for individuals to schedule their vaccinations based on their menstrual cycles; vaccines can be given to those currently menstruating.

Information for patients can be found on ACOG’s patient website: Coronavirus (COVID-19) and Women’s Health Care: A Message for Patients.

Health Equity Considerations and Communities of Color

Communities of color have been disproportionately affected by the COVID-19 pandemic. Individuals in communities of color are more likely to have severe illness and even die from COVID-19, likely because of a range of social and structural factors, including disparities in socioeconomic status, access to care, rates of chronic conditions, occupational exposures, systemic racism, and historic and continued inequities in the health care system. Access to and confidence in COVID-19 vaccines are of critical importance for all communities, but the willingness to consider vaccination varies by patient context, in part because of historic and continued injustices and systemic racism that have eroded trust in some communities of color. With time, greater proportions of Black Americans have expressed a desire for vaccination such that the majority surveyed affirm their intent for vaccination (Pew Research Center 2021). Despite intent to obtain vaccination, inequities in vaccine distribution persist. Recent data suggest that, although disparities in access have narrowed over recent months, Black and Latinx populations generally remain vaccinated at lower rates than others, in part related to differential access (Kaiser Family Foundation 2021). With the spread of the more transmissible variants, which most profoundly affect unvaccinated people, equitable vaccine access remains essential.

Obstetrician–gynecologists have the unique responsibility of counseling their patients, including people who are pregnant and lactating, through their COVID-19 vaccination decisions. For tools on discussing COVID-19 vaccines with your patients, COVID-19 Vaccine Confidence Training, and additional resources, please visit ACOG’s COVID-19 Topic Page.

Vaccine Confidence

Vaccine hesitancy, particularly around COVID-19 vaccines, exists among all populations. Provider recommendations for vaccination are associated with the highest likelihood of patient vaccine receipt (Nguyen 2021). When communicating with patients, it is extremely important to provide a strong recommendation for vaccines as well as to underscore the general safety of vaccines and emphasize the fact that no steps were skipped in the development and evaluation of COVID-19 vaccines. This can be done by briefly highlighting the safety requirements of vaccines and ongoing safety monitoring even after vaccines are made available.

For tools on discussing COVID-19 vaccines with your patients, COVID-19 Vaccine Confidence Training, and additional resources, please visit ACOG’s COVID-19 Topic Page.