COVID-19 Vaccines and Pregnancy: Conversation Guide

Key Recommendations

• The American College of Obstetricians and Gynecologists (ACOG) strongly recommends that pregnant individuals be vaccinated against COVID-19. Given the potential for severe illness and death during pregnancy, completion of the initial COVID-19 vaccination series is a priority for this population.
• mRNA COVID-19 vaccines are preferred over the J&J/Janssen COVID-19 vaccine for primary series, additional doses (for immunocompromised persons), and for booster vaccination.
• ACOG recommends that pregnant and recently pregnant people up to 6 weeks postpartum receive a bivalent mRNA COVID-19 vaccine booster dose following the completion of their last COVID-19 primary vaccine dose or monovalent booster.
• Vaccination may occur in any trimester, and emphasis should be on vaccine receipt as soon as possible to maximize maternal and fetal health. This recommendation applies to both primary series and booster vaccination.
• 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.
• COVID-19 vaccines may be administered simultaneously with other vaccines, including within 14 days of receipt of another vaccine. This includes vaccines routinely administered during pregnancy, such as the influenza and Tdap vaccines.
• Pregnant patients who get vaccinated should be encouraged to sign up for the v-safe safety monitoring program of the Centers for Disease Control and Prevention (CDC).

Key Messages

The following messages are intended to help guide conversations with pregnant patients:

Risk Associated With COVID-19 Infection During Pregnancy

• COVID-19 infection during pregnancy is associated with increased risk of maternal severe illness, admission to an intensive care unit, mechanical ventilation, and death.
• There is a known increased risk of complications from COVID-19 in pregnant patients with underlying health conditions (e.g., diabetes, obesity, increasing age, and cardiovascular disease).
• There is an increased risk of preterm delivery, and there may be an increased risk of stillbirth.
• There is increased risk of infection and death for certain racial and ethnic populations.

Safety of COVID-19 Vaccines

• None of the COVID-19 vaccines available for use under emergency use authorization or U.S. Food and Drug Administration (FDA) license causes infertility or spontaneous abortion.
• There is no evidence of adverse maternal or fetal effects from vaccinating pregnant individuals with the COVID-19 vaccine, and a growing body of data demonstrates the safety of such use.
• Injection site and systemic events (side effects) are common (e.g., pain at the site of injection, fever, muscle pain, joint pain, headaches, fatigue, and other symptoms may be present after vaccination).
  • Acetaminophen is recommended for pregnant women who experience fever or if desired for other side effects.
  • These side effects are a normal part of the body’s reaction to the vaccine and developing antibodies to protect against COVID-19 illness.
• Ongoing safety monitoring is occurring through many government and nongovernment programs.
• For information on the rare risk of thrombosis with thrombocytopenia syndrome, Guillain–Barré syndrome, and myocarditis, see ACOG’s Practice Advisory COVID-19 Vaccination Considerations for Obstetric–Gynecologic Care.

Other safety programs include the following:

• Vaccine Adverse Event Reporting System (VAERS)
• Vaccine Safety Datalink (VSD)
• Manufacturer-sponsored reporting systems:
  • Pfizer-BioNTech
  • Moderna
  • J&J/Janssen
  • Novavax

Efficacy of COVID-19 Vaccines

• There are limited data available on the efficacy of COVID-19 vaccines in pregnancy, but so far, the vaccines appear to be equally effective in pregnant individuals and nonpregnant individuals.
• All currently available COVID-19 vaccines have demonstrated high efficacy among their respective clinical trial endpoints.
• Two doses of mRNA (Pfizer-BioNTech or Moderna) and Novavax vaccines are necessary to achieve protection in immunocompetent individuals.
• One dose of adenovirus vector vaccine (J&J/Janssen) is necessary to achieve protection.
• Moderately to severely immunocompromised individuals (i.e., people who have undergone solid organ transplantation or have been diagnosed with conditions that are considered to have an equivalent level of immunocompromise) should receive an additional dose (i.e., an additional primary dose) of COVID-19 vaccine after their initial vaccine or vaccine series. The additional dose should be administered four weeks after the completion of the initial COVID-19 vaccine or vaccine series. For mRNA vaccines, this means immunocompromised individuals need a 3-dose primary series. For J&J/Janssen vaccine, immunocompromised individuals need a 2-dose primary series with the second dose being an mRNA vaccine.
  • Currently, an additional dose using any COVID-19 vaccine is not authorized for individuals who receive Novavax COVID-19 vaccine as their primary series
• ACOG recommends that pregnant and recently pregnant people up to 6 weeks postpartum receive a bivalent mRNA COVID-19 vaccine booster dose following the completion of their last COVID-19 primary vaccine dose or monovalent booster.
• COVID-19 vaccines decrease the risk of severe COVID-19 disease.
  • Even if the patient gets sick after being vaccinated, their chance of becoming severely ill are extremely low.
• The majority of hospitalized patients are individuals who did not receive a COVID-19 vaccine.

Safety and Efficacy for the Newborn

• There are accumulating data demonstrating that antibodies are passed to the fetus when a pregnant person is vaccinated.
  • IgG antibodies after maternal vaccination in the third trimester have been shown in observational studies. However, no data are available to demonstrate whether this prevents COVID-19 disease in neonates.
• mRNA vaccines are available to children aged 6 months and older. 

Special Considerations for Communities of Color

• Access to and confidence in COVID-19 vaccines are of critical importance for all communities, but 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. When discussing COVID-19 vaccines with an individual who expresses concerns, it is critical to:
  • Be aware of historical and current injustices perpetrated against communities of color.
  • Actively listen to and validate expressed fears and concerns.
  • Continue to care for patients who decide not to be vaccinated, to share resources, and to encourage the continued use of prevention measures.

Continued Support

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
• wearing a mask

For more information on vaccinating pregnant women against COVID-19, see ACOG’s Practice Advisory.

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