Protecting pregnant women and their newborns by offering timely and effective vaccinations is a critical component of disease prevention, particularly given the rise of vaccine-preventable disease in the United States and around the globe. Studies show that when clinicians are knowledgeable about the benefits of vaccines and offer them to their patients, uptake of vaccination rises.1–4 This is particularly true during pregnancy, when patients are concerned about vaccine safety and efficacy.5
In this review, we provide an
evidence-based summary of the vaccines that are recommended for women preconception, during pregnancy, and postpartum and provide counseling tips to help providers achieve the highest vaccine uptake rates possible.
The preconception period offers a unique opportunity to optimize a woman’s health for pregnancy and beyond.
Influenza infection during pregnancy has been associated with severe maternal illness, pregnancy loss, and preterm birth.6 Immunity confers significant benefits to both pregnant women and their offspring.7 Generally available for administration from late August through March of each year to correspond with the influenza season (timing may vary by region), the trivalent or quadrivalent, inactivated influenza vaccine should be given to all individuals older than age 6 months, including women considering pregnancy. Do not administer live vaccine (LAIV, Flumist) to women who may be pregnant but there is no contraindication to their family members receiving the live vaccine.8
Measles, mumps, and rubella (MMR)
Given the global measles outbreak, the Centers for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists (ACOG) recommend assessing measles immunity in addition to rubella immunity.9 The CDC recommends an evaluation of either a patient’s vaccine record or confirmatory measles serology to prove immunity (Table 1).10 While a single prior MMR dose may be adequate for some women, patients at high risk for exposure to measles should demonstrate proof of two doses. Many providers ask if the demonstration of rubella immunity from a prior pregnancy is adequate to confirm measles immunity. While rubella immunity is generally correlated with receipt of at least one MMR vaccine, that is not a valid surrogate for measles immunity. If the appropriate number of MMR doses has not been documented or the vaccine record is not available, measles serology can be obtained, and an MMR vaccine booster administered to patients with a negative Measles IgG antibody result. After receiving the MMR vaccine—a live, attenuated vaccine—women should wait 4 weeks prior to attempting pregnancy, given theoretical risks to the fetus with live vaccines.11 However, if pregnancy occurs inadvertently within the 4-week window, patients should be reassured that there have been no reports of fetal harm due to this exposure.
Assessing rubella immunity has been a longstanding part of prenatal testing given the preventability of congenital rubella syndrome for those who have been adequately vaccinated with MMR. Therefore, women who are either measles non-immune or rubella non-immune should be vaccinated in the preconception period.
- Finney Rutten LJ, St Sauver JL, Beebe TJ, et al. Association of both consistency and strength of self-reported clinician recommendation for HPV vaccination and HPV vaccine uptake among 11- to 12-year-old children. Vaccine. 2017;35(45):6122-6128.
- Rutten LJF, St Sauver JL, Beebe TJ, et al. Clinician knowledge, clinician barriers, and perceived parental barriers regarding human papillomavirus vaccination: Association with initiation and completion rates. Vaccine. 2017;35(1):164-169.
- Martinello RA, Jones L, Topal JE. Correlation between healthcare workers’ knowledge of influenza vaccine and vaccine receipt. Infect Control Hosp Epidemiol. 2003;24(11):845-847.
- 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-S74.
- Goldfarb I, Panda B, Wylie B, Riley L. Uptake of influenza vaccine in pregnant women during the 2009 H1N1 influenza pandemic. Am J Obstet Gynecol. 2011;204(6 Suppl 1):S112-S115.
- ACOG Committee Opinion No. 732: Influenza Vaccination During Pregnancy. Obstet Gynecol. 2018;131(4):e109-e114.
- Mølgaard-Nielsen D, Fischer TK, Krause TG, Hviid A. Effectiveness of maternal immunization with trivalent inactivated influenza vaccine in pregnant women and their infants. J Intern Med. July 2019.
- Grohskopf LA, Alyanak E, Broder, KR et al . Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2019–20 Influenza Season. MMWR Recomm Rep. 2019;68(3); 1-21.
- Measles & the MMR Vaccine: Recommendations Around Pregnancy, Including the Periconception and Postpartum Periods - UW Medicine Provider Resource. http://providerresource.uwmedicine.org/flexpaper/measles-and-the-mmr-vaccine-recommendations-around-pregnancy-including-the-periconception-and-postpartum-periods. Accessed September 25, 2019.
- Centers for Disease Control and Prevention. Measles: Evidence of Immunity. https://www.cdc.gov/measles/hcp/index.html#immunity.
- McLean HQ, Fiebelkorn AP, Temte JL, et al. Centers for Disease Control and Prevention. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013;62(RR-04):1-34.
- Marin M, Güris D, Chaves SS, S et al. Centers for Disease Control and Prevention (CDC). Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56(RR-4):1-40.
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 86: Viral hepatitis in pregnancy. Obstet Gynecol. 2007;110(4):941-956.
- Mast EE, Weinbaum CM, Fiore AE, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults. MMWR Recomm Rep. 2006;55(RR-16):1-33; quiz CE1-CE4.
- Fiore AE, Wasley A, Bell BP. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55(RR-7):1-23.
- Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012;61(40):816-819.
- Centers for Disease Control and Prevention (CDC), Advisory Committee on Immunization Practices. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR Morb Mortal Wkly Rep. 2010;59(34):1102-1106.
- Pneumococcal Vaccination Summary | Who and When to Vaccinate | For Providers | CDC. https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html. Published June 20, 2019. Accessed September 25, 2019.
- HPV Vaccine Recommendations | Human Papillomavirus | CDC. https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html. Published June 27, 2019. Accessed September 25, 2019.
- Committee Opinion No. 704 Summary: Human Papillomavirus Vaccination. Obstet Gynecol. 2017;129(6):1155-1156.
- Use of Standing Orders Programs to Increase Adult Vaccination Rates: Recommendations of the Advisory Committee on Immunization Practices. https://www.cdc.gov/mmwr/PDF/rr/rr4901.pdf.
- Committee on Obstetric Practice, Immunization and Emerging Infections Expert Work Group. Committee Opinion No. 718: Update on Immunization and Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination. Obstet Gynecol. 2017;130(3):e153-e157.
- ACOG Committee Opinion No. 741: Maternal Immunization. Obstet Gynecol. 2018;131(6):e214-e217.