SOGC Clinical Practice Guideline
No. 357-Immunization in Pregnancy

https://doi.org/10.1016/j.jogc.2017.11.010Get rights and content

Abstract

Objective

To review the evidence and provide recommendations on immunization in pregnancy.

Outcomes

Outcomes evaluated include effectiveness of immunization and risks and benefits for mother and fetus.

Evidence

The Medline and Cochrane databases were searched for articles published up to January 2017 on the topic of immunization in pregnancy.

Values

The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1).

Benefits, Harms, and Costs

Implementation of the recommendations in this guideline should result in more appropriate immunization of pregnant and breastfeeding women, decreased risk of contraindicated immunization, and better disease prevention.

Recommendations

  • 1.

    Health care providers should obtain a relevant immunization history from all women accessing prenatal care and offer vaccinations as indicated (III-A).

  • 2.

    In general, live and/or live-attenuated virus vaccines should not be administered during pregnancy because there is a largely theoretical risk to the fetus (II-3B).

  • 3.

    Women who have inadvertently received vaccination with a live or live-attenuated vaccine during pregnancy should not be counselled to terminate the pregnancy for the reason of a teratogenic risk (II-2A).

  • 4.

    Non-pregnant women receiving a live or live-attenuated vaccine should be counselled to delay pregnancy for at least 4 weeks (III-B).

  • 5.

    Inactivated viral vaccines, bacterial vaccines, and toxoids can be used safely in pregnancy (II-1A).

  • 6.

    Breastfeeding is not a contraindication to vaccination (passive-active immunization, live, with the exception of yellow fever, or killed vaccines) (II-1A).

  • 7.

    All pregnant women should be offered the diphtheria and tetanus toxoids and acellular pertussis vaccine during the second or third trimester, preferably between 21 and 32 weeks gestation, during every pregnancy, irrespective of their immunization history (II-2A).

  • 8.

    All pregnant women, at any stage in pregnancy, or women who might be pregnant in the upcoming influenza season, should be offered the inactivated influenza vaccine for the prevention of maternal and infant influenza-related morbidity and mortality (I-1A).

  • 9.

    Pregnant women with suspected or documented influenza infection, regardless of immunization history, should be treated with oseltamivir (Tamiflu, 75 mg po twice daily) (III-B).

  • 10.

    Some pregnant women should be offered the hepatitis B, hepatitis A, meningococcal, and/or pneumococcal vaccines for the prevention of maternal morbidity if they have specific risk factors by means of their medical comorbidities or specific exposures (III-A).

Introduction

Immunization programs are among the most cost-beneficial health interventions. Women interact with the health care system regularly during the preconception period and during pregnancy; therefore, obstetrical care providers are well-placed to review their immunization status and recommend vaccinations. This can significantly reduce the occurrence of preventable diseases, benefiting not only the woman and her infant but also the rest of the population.

The overall objective of vaccination in pregnancy is to induce a state of immunity such that the woman and the fetus are protected following exposure to the organism for which the immunization is given. In addition, this offers an opportunity for protection of the neonate for the first few months of life.

Vaccines may be prepared from various sources, including the inactivated agent, live-attenuated agent and modified and single antigen recombinant forms of the organism. Active immunization relies on the administration of antigens and results in a prompt but transient IgM response in the host. This is followed by a rise in IgG antibody production that will be more or less sustained. In cases in which the response is not sustained, booster doses may be required for long-term immune memory. Of note, oral vaccines will stimulate IgA initially as opposed to IgM (parenteral).

This document reviews indications for and contraindications to immunization during pregnancy and makes recommendations for the use of specific vaccines during pregnancy, acknowledging that immunization schedules in Canada vary according to province and territory, despite calls for harmonization1, 2 (Table 2).

Section snippets

Importance of the Prenatal Care Provider as an Immunization Advocate

Prenatal care providers should obtain a thorough immunization history. In many cases, women present for prenatal care without having had their immunization status reviewed since they completed the school-age vaccination schedule. Digital tools like CANimmunize (digital immunization record for all Canadians to securely track, store, and update immunization records on a smartphone) can facilitate this review.

Prenatal care provides a unique window of opportunity to offer specific killed or

Live and Live-Attenuated Vaccines

In general, live and/or live-attenuated virus vaccines are contraindicated during pregnancy because there is a theoretical risk of infection to the fetus. To date, however, there is no evidence to demonstrate a teratogenic risk from any currently available live product (e.g., MMR, varicella).7, 8 Hence, inadvertent vaccination should not be an indication for termination of pregnancy. With the exception of the yellow fever vaccine, these products are safe and acceptable for breastfeeding mothers.

Hepatitis B Vaccine

Acute maternal hepatitis B infection during pregnancy poses a high risk of mother-to-child transmission (up to 60% in the third trimester). These infants have a 70% to 90% risk of chronic hepatitis B infection. Pregnant women at high risk for acquiring hepatitis B infection during pregnancy (e.g., more than 1 sex partner during the previous 6 months, been evaluated or treated for a sexually transmitted disease, recent or current injection drug use, having had a hepatitis B-infected sex partner,

Side Effects of Vaccines and Contraindications

Vaccines may cause various side effects, which should not all be interpreted as contraindications. Side effects can be divided in the following 5 categories: (1) immediate/early, (2) local, (3) systemic, (4) allergic, and (5) long term.

  • 1.

    Immediate/early effects include fainting and vasovagal reactions. These are differentiated from anaphylactic shock (see in the following list). Patients who have received a vaccine should be kept in the waiting room for observation for 15 to 30 minutes.

  • 2.

    Local

Conclusion

The development of new vaccines and the accumulating information about vaccine safety ensure that health care providers can provide immunizations and/or advice about immunization for their pregnant patients. This is most important in disease prevention, and antenatal care providers must play an active role in vaccine counselling and administration. Furthermore, it is imperative that more research efforts be focused in the area of immunization in pregnancy.

Acknowledgements

The authors and Infectious Diseases Committee wish to thank Dr. Andrée Gruslin, Dr. Marc Steben, Dr. Scott Halperin, and Dr. Deborah Money for their input and contributions to the original version of the guideline.

References (80)

  • B. Abu Raya et al.

    Immunization of pregnant women against pertussis: the effect of timing on antibody avidity

    Vaccine

    (2015)
  • K. Maertens et al.

    Avidity of maternal pertussis antibodies after vaccination during pregnancy

    Vaccine

    (2015)
  • H.T. Hoang et al.

    Pertussis vaccination during pregnancy in Vietnam: results of a randomized controlled trial Pertussis vaccination during pregnancy

    Vaccine

    (2016)
  • G. Amirthalingam et al.

    Effectiveness of maternal pertussis vaccination in England: an observational study

    Lancet

    (2014)
  • E.A. Talbot et al.

    The safety of immunizing with tetanus-diphtheria-acellular pertussis vaccine (Tdap) less than 2 years following previous tetanus vaccination: experience during a mass vaccination campaign of healthcare personnel during a respiratory illness outbreak

    Vaccine

    (2010)
  • D.W. Freeman et al.

    Deaths from Asian influenza associated with pregnancy

    Am J Obstet Gynecol

    (1959)
  • D.L. Schanzer et al.

    Influenza-attributed hospitalization rates among pregnant women in Canada 1994–2000

    J Obstet Gynaecol Can

    (2007)
  • C.D. Chambers et al.

    Safety of the 2010–11, 2011–12, 2012–13, and 2013–14 seasonal influenza vaccines in pregnancy: birth defects, spontaneous abortion, preterm delivery, and small for gestational age infants, a study from the cohort arm of VAMPSS

    Vaccine

    (2016)
  • J.G. Donahue et al.

    Association of spontaneous abortion with receipt of inactivated influenza vaccine containing H1N1pdm09 in 2010–11 and 2011–12

    Vaccine

    (2017)
  • P.D. Tamma et al.

    Safety of influenza vaccination during pregnancy

    Am J Obstet Gynecol

    (2009)
  • D.J. Jamieson et al.

    H1N1 2009 influenza virus infection during pregnancy in the USA

    Lancet

    (2009)
  • P.M. Grosheide et al.

    Immune response to hepatitis B vaccine in pregnant women receiving post-exposure prophylaxis

    Eur J Obstet Gynecol Reprod Biol

    (1993)
  • N. Macdonald et al.

    A harmonized immunization schedule for Canada: a call to action

    Paediatr Child Health

    (2011)
  • B.A. Halperin et al.

    Maintaining the momentum: key factors influencing acceptance of influenza vaccination among pregnant women following the H1N1 pandemic

    Hum Vaccin Immunother

    (2014)
  • G. Blanchard-Rohner et al.

    Acceptability of maternal immunization against influenza: the critical role of obstetricians

    J Matern Fetal Neonatal Med

    (2012)
  • O.P. Heinonen et al.

    Immunizing agents

  • J.C. Watson et al.

    Measles, mumps, and rubella—vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP)

    MMWR Recomm Rep

    (1998)
  • H.Q. McLean et al.

    Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP)

    MMWR Recomm Rep

    (2013)
  • H. Zealley et al.

    Rubella screening and immunisation of schoolgirls: results six to seven years after vaccination

    Br Med J (Clin Res Ed)

    (1982)
  • P.P. Mortimer et al.

    Are many women immunized against rubella unnecessarily?

    J Hyg (Lond)

    (1981)
  • Public Health Agency of Canada

    Canadian immunization guide: part 1—Key Immunization Information

  • A.A. Gershon

    Chicken pox, measles and mumps

  • Public Health Agency of Canada

    Varicella (chickenpox) vaccine

    (2016)
  • D.P. Cavalcanti et al.

    Early exposure to yellow fever vaccine during pregnancy

    Trop Med Int Health

    (2007)
  • Public Health Agency of Canada

    Pertussis (whooping cough)

    (2014)
  • G. Amirthalingam et al.

    Pertussis immunisation and control in England and Wales, 1957 to 2012: a historical review

    Euro Surveill

    (2013)
  • S.A. Gall et al.

    Maternal immunization with tetanus-diphtheria-pertussis vaccine: effect on maternal and neonatal serum antibody levels

    Am J Obstet Gynecol

    (2011)
  • C.S. Eberhardt et al.

    Maternal immunization earlier in pregnancy maximizes antibody transfer and expected infant seropositivity against pertussis

    Clin Infect Dis

    (2016)
  • A. Calvert et al.

    Placental transfer of antibody and its relationship to vaccination in pregnancy

    Curr Opin Infect Dis

    (2017)
  • C.M. Healy et al.

    Importance of timing of maternal combined tetanus, diphtheria, and acellular pertussis (Tdap) immunization and protection of young infants

    Clin Infect Dis

    (2013)
  • Cited by (15)

    • Performance evaluation of the bio-rad BioPlex 2200 multiplex system in the detection of measles, mumps, rubella, and varicella-zoster antibodies

      2023, Journal of Clinical Virology Plus
      Citation Excerpt :

      According to the 2017 Childhood National Immunization Coverage Survey (cNICS), over 90% of Canadian 2-year-olds are vaccinated against MMR and 83% are vaccinated against varicella[2]. Despite this progress, several populations remain at risk for MMRV infection including healthcare workers (HCW), pregnant women, and individuals who are immunocompromised[3,4]. Additionally, declining immunization rates, vaccine failures, and waning immunity are contributing to the risk of viral outbreak[5,6].

    • Pertussis Vaccination in Canadian Pregnant Women, 2018–2019

      2022, Journal of Obstetrics and Gynaecology Canada
      Citation Excerpt :

      For these reasons, the National Advisory Committee on Immunization recommended in February 2018 that Tdap be administered in every pregnancy in Canada, ideally between 27 and 32 weeks of gestation.9 In March 2018, the Society of Obstetricians and Gynaecologists of Canada issued a new clinical practice guideline on immunization in pregnancy that included a recommendation that every pregnant woman be offered Tdap, ideally between 21 and 32 weeks.10 As of November 2019, all provinces and territories except for Ontario and British Columbia had implemented programs to provide pertussis vaccination free of charge to pregnant women.

    • Immunization in Pregnancy: The Future for Neonatal Protection

      2018, Journal of Obstetrics and Gynaecology Canada
    • L'immunisation pendant la grossesse : l'avenir de la protection néonatale

      2018, Journal of Obstetrics and Gynaecology Canada
    • Vaccination during pregnancy: A golden opportunity to embrace

      2023, International Journal of Gynecology and Obstetrics
    View all citing articles on Scopus

    This document reflects emerging clinical and scientific advances on 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. Local institutions can dictate amendments to these opinions. They should be well-documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the publisher.

    Women have the right and responsibility to make informed decisions about their care in partnership with their health care providers. To facilitate informed choice, women should be provided with information and support that is evidence based, culturally appropriate, and tailored to their needs. The values, beliefs, and individual needs of each woman and her family should be sought, and the final decision about the care and treatment options chosen by the woman should be respected.

    View full text