Preconception and Pregnancy Vaccination Guidelines

Influenza Vaccination

• The Centers for Disease Control and Prevention recommends that women planning pregnancy receive the inactivated influenza vaccine before conception if they will be pregnant during flu season to establish maternal immunity that protects both mother and fetus 1.
• The American College of Obstetricians and Gynecologists suggests that the vaccine can be given at any time during pregnancy if not received preconception, as pregnancy is not a contraindication to inactivated influenza vaccine 2.
• Pregnant women face disproportionately higher risks from influenza infection, including increased rates of severe illness and adverse pregnancy outcomes, making vaccination critical 3.
• Only use inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV)—never live attenuated influenza vaccine (LAIV) in women who are or may become pregnant, as LAIV is contraindicated due to theoretical risk of placental viral transmission 2, 4.

Tdap Vaccination

• The Advisory Committee on Immunization Practices recommends that Tdap is NOT routinely recommended preconception—instead, it should be administered during each pregnancy between 27-36 weeks' gestation, regardless of prior vaccination history 1, 5.
• Administering Tdap between 27-36 weeks' gestation maximizes transplacental antibody transfer to provide passive immunity to the newborn 1, 5.
• The only situation where preconception Tdap may be considered is for women who have not received Tdap previously AND are at increased risk for pertussis exposure 1, 5.
• If Tdap is not given during pregnancy, it should be administered immediately postpartum (before hospital discharge) if the woman never received Tdap during pregnancy or at any prior time 1, 5.

Special Considerations

• Severe allergic reaction (anaphylaxis) to any vaccine component is an absolute contraindication to Tdap 2.
• Moderate or severe acute illness with or without fever is a precaution for Tdap, and vaccination should be deferred until the condition is resolved 2.
• Guillain-Barré syndrome within 6 weeks of previous tetanus toxoid-containing vaccine is a precaution for Tdap, and vaccination should be deferred 2.
• Stable neurologic conditions, including well-controlled seizures, are not contraindications to Tdap 6.
• Immunosuppression or HIV infection are not contraindications to Tdap, though immunogenicity may be suboptimal 6.
• Breastfeeding is not a contraindication to Tdap 6.
• Minor concurrent illness is not a contraindication to Tdap 6.

Vaccination Guidelines During Pregnancy

Vaccines Safe During Pregnancy

• The American College of Obstetricians and Gynecologists recommends the inactivated influenza vaccine for all pregnant women during any trimester, providing both maternal protection and passive immunity to the newborn through transplacental antibody transfer 7, 8
• The Centers for Disease Control and Prevention strongly recommends the COVID-19 vaccine for all pregnant women, given that pregnant women face 2-3 fold higher rates of ICU admission, invasive ventilation, and mortality from COVID-19 compared to non-pregnant women 9
• The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists routinely recommend the Tdap/Whooping Cough vaccine during each pregnancy between 27-36 weeks gestation, providing crucial protection to newborns during their most vulnerable period before they can receive their own vaccinations 8, 10

HPV Vaccination Guidelines

• The Advisory Committee on Immunization Practices explicitly contraindicates HPV vaccination during pregnancy, and the vaccine should be deferred until after pregnancy completion, according to the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention 11, 12
• Preconception administration of the HPV vaccine series (3 doses through age 26 years) is recommended before pregnancy, and the series should be resumed or completed immediately after delivery 11, 12

Vaccination Guidelines for Pregnant Women

Tetanus-Diphtheria Vaccination

• The Centers for Disease Control and Prevention recommends that unvaccinated or incompletely vaccinated women begin a primary series consisting of three doses of Td during pregnancy, with the first two doses administered at least 4 weeks apart and the third dose given 6-12 months after the second dose 13, 14
• Women who have completed a primary series but have not received a booster in 10 years or more should receive a Td booster at the first visit 13, 14
• The American College of Obstetricians and Gynecologists recommends that women who previously received only one or two doses of Td complete their primary series during pregnancy 13, 14

Hepatitis B Vaccination

• The Centers for Disease Control and Prevention recommends prenatal screening of all pregnant women for HBsAg, and if the patient is at risk and not previously vaccinated, hepatitis B vaccine can be safely administered during pregnancy 13, 14
• Pregnancy or lactation should not be considered a contraindication to hepatitis B vaccine for persons who are otherwise eligible 13, 14

Vaccines to Avoid During Pregnancy

• Live-virus vaccines, such as MMR, varicella, and LAIV, should not be given to pregnant women due to theoretical risk to the developing fetus, and should be administered postpartum, preferably before hospital discharge 13, 14

Best Practices

• The American College of Obstetricians and Gynecologists recommends that vaccination history be documented thoroughly to determine whether a primary series or booster is needed 13, 14
• Skipping the Td booster at the first visit if indicated can leave the mother unprotected against tetanus and diphtheria throughout pregnancy 13, 14

Tetanus Toxoid Vaccination During Breastfeeding

Introduction to Guideline Recommendations

• The Centers for Disease Control and Prevention (CDC) recommends that breastfeeding mothers receive tetanus toxoid-containing vaccines (Td or Tdap) without hesitation for wound management or routine immunization, as they are safe to administer during breastfeeding 15, 16

Direct Guideline Recommendations

• The Advisory Committee on Immunization Practices (ACIP) recommends that women who are breastfeeding should receive Tdap in the immediate postpartum period if not previously vaccinated, ideally before hospital discharge, as breastfeeding is not a contraindication to Tdap or tetanus toxoid-containing vaccines 15, 16
• Breastfeeding mothers requiring tetanus prophylaxis due to animal bites or other wounds should receive tetanus toxoid-containing vaccine according to standard wound management protocols, as recommended by the CDC 17, 18
• The American Academy of Pediatrics (AAP) and the CDC state that breastfeeding status does not alter the timing or safety of routine Td boosters 19

Clinical Application for Wound Management

• For a breastfeeding mother with an animal bite requiring tetanus prophylaxis, if ≥5 years have elapsed since last Td booster, administer Tdap (if never received) or Td (if previously received Tdap) according to standard wound management guidelines, as recommended by the CDC 17, 18
• If <5 years since last tetanus-containing vaccine AND completed primary series, no tetanus vaccine is needed for wound management, according to the CDC 17, 20
• Tetanus immune globulin (TIG) may also be indicated depending on wound characteristics and vaccination history, administered at a separate anatomic site, as recommended by the CDC 17, 20

Safety Evidence

• Inactivated vaccines and toxoids (including tetanus toxoid) pose no theoretical risk to breastfeeding infants, as these are not live vaccines, according to the CDC 15, 16
• Large-scale use of tetanus toxoid in pregnant and postpartum women worldwide has not identified clinically significant adverse events affecting mothers or infants, as reported by the CDC 21, 22
• Postpartum Tdap administration is specifically recommended for breastfeeding women to protect both the mother and reduce pertussis transmission risk to the infant, as recommended by the CDC and the AAP 15, 16, 19

Simultaneous Administration of Vitamin B12 and Tdap in Pregnancy

Rationale for Simultaneous Administration

• Inactivated vaccines, including Tdap, may be administered at any time before or after a different inactivated or live vaccine, unless a specific contraindication exists, according to the Centers for Disease Control and Prevention 23
• Simultaneous administration of vaccines is preferred when both are indicated during the same visit, as recommended by the Centers for Disease Control and Prevention 23
• Vitamin B12 supplementation is not a vaccine and poses no interaction concerns with Tdap administration, as stated by the Centers for Disease Control and Prevention 23

Clinical Application

• If a pregnant patient requires both vitamin B12 supplementation and Tdap vaccination, administer both during the same visit without concern for interaction, as recommended by the Centers for Disease Control and Prevention 23
• There is no need to separate these interventions by days or weeks, according to the Centers for Disease Control and Prevention 23

Common Pitfalls to Avoid

• Do not unnecessarily delay Tdap vaccination due to concerns about vitamin supplementation, as there is no biological basis for this concern, according to the Centers for Disease Control and Prevention 23

HPV Vaccine Contraindication in Pregnancy

Official Recommendation

Rationale for Precaution

Safety Evidence from Exposure Registries