Vaccination Recommendations During Pregnancy

Routinely Recommended Vaccines

• The CDC and WHO strongly recommend that all pregnant women receive the inactivated influenza vaccine during any trimester and the Tdap vaccine between 27-36 weeks of gestation in every pregnancy to protect both mother and infant from severe disease and mortality 1, 2, 3
• One dose of inactivated influenza vaccine is recommended during any trimester of pregnancy, ideally before flu season begins 1, 3
• Pregnant women are at significantly higher risk for severe disease, hospitalization, and death from influenza compared to non-pregnant women 2, 4
• Influenza infection during pregnancy is associated with adverse pregnancy outcomes including late pregnancy loss and reduced infant birthweight 2
• The live attenuated influenza vaccine (nasal spray) is contraindicated during pregnancy 4
• One dose of Tdap vaccine is recommended between 27 and 36 weeks of gestation in every pregnancy 1, 5, 6
• Optimal timing is 27-28 weeks to maximize maternal antibody response and passive antibody transfer to the infant 6
• If not previously vaccinated and dose not administered during pregnancy, give immediately postpartum 6
• For wound management during pregnancy, Tdap should replace Td if ≥5 years since previous booster 6

Contraindicated Vaccines During Pregnancy

• Live attenuated vaccines are generally contraindicated during pregnancy due to theoretical risk of placental transmission 7, 8
• These include: Measles, mumps, rubella (MMR) 7, 8, Varicella (chickenpox) 7, 8, Smallpox (vaccinia) 7, and Live attenuated influenza vaccine (nasal spray) 4

Vaccines for High-Risk Situations

• Hepatitis B vaccine is recommended for pregnant women at risk for hepatitis B virus infection 7, 8
• Pneumococcal, meningococcal, and hepatitis A vaccines should be considered for pregnant women at increased risk 7, 8
• Yellow fever vaccine should be administered to pregnant women who must travel to high-risk areas, as the risk of infection outweighs theoretical vaccination risks 7, 8

Important Clinical Considerations

• All pregnant women should be evaluated for immunity to rubella and tested for HBsAg in every pregnancy 7
• Women susceptible to rubella and varicella should be vaccinated immediately after delivery 7
• Vaccination coverage rates among pregnant women remain suboptimal, with influenza vaccination rates in the US at only 61.2% 2
• Addressing vaccine hesitancy through education about benefits to both mother and infant is important 3

Common Pitfalls to Avoid

• Delaying influenza vaccination until a specific trimester - it can be given at any time during pregnancy 1, 3
• Missing the optimal window (27-36 weeks) for Tdap administration 6
• Not addressing vaccine hesitancy through education about benefits to both mother and infant 3

Vaccination Guidelines During Pregnancy

Contraindicated and Safe Vaccines

• The Centers for Disease Control and Prevention recommends that live attenuated zoster vaccine (Zostavax) is absolutely contraindicated during pregnancy due to the theoretical risk of placental transmission of the live virus 9
• The American College of Obstetricians and Gynecologists suggests that the recombinant zoster vaccine (RZV/Shingrix) should be delayed until after pregnancy if indicated, though it is not an absolute contraindication like the live vaccine 9
• The American College of Obstetricians and Gynecologists recommends that Hepatitis B vaccine can be safely offered to pregnant women at high risk for hepatitis B virus infection or who desire vaccination 10, 11
• The Centers for Disease Control and Prevention recommends that Meningococcal conjugate vaccines (MenACWY) are recommended for pregnant women with additional risk factors, and pregnancy should not preclude their use when otherwise indicated 9, 10

Vaccines to Delay

• The Centers for Disease Control and Prevention suggests that HPV vaccine should be delayed until after pregnancy, but this is a precautionary recommendation rather than an absolute contraindication 9

Key Clinical Distinctions

• The Advisory Committee on Immunization Practices states that live attenuated zoster vaccine poses theoretical risk of fetal infection through placental viral transmission, which is why it carries an absolute contraindication 9
• The American College of Obstetricians and Gynecologists notes that hepatitis B (inactivated), meningococcal (conjugate/polysaccharide), and HPV (recombinant) vaccines do not contain live replicating organisms and therefore do not carry the same theoretical risk of fetal infection 10, 11

Hepatitis B Vaccination in Pregnancy – CDC Guideline Summary

Indications and Target Populations

• Pregnant individuals at risk for hepatitis B virus infection—such as those with multiple sexual partners, a partner with hepatitis B, injection drug use, or household contact with a chronically infected person—should be offered hepatitis B vaccination. 12, 13

Safety Profile

• Hepatitis B vaccination is safe for both the pregnant individual and the fetus throughout all trimesters; the vaccine contains non‑infectious hepatitis B surface antigen particles that pose no fetal risk. 12, 13, 14, 15
• Aggregate data from multiple studies show no increased risk of adverse fetal outcomes (abortion, stillbirth, congenital malformations, or sudden infant death syndrome) following vaccination during pregnancy. 14, 15

Vaccination Schedule and Administration

• The standard three‑dose series (0 months, 1 month, 6 months) may be initiated and completed during pregnancy. 15
• The vaccine must be administered intramuscularly in the deltoid muscle; administration in the buttock markedly reduces immunogenicity and should be avoided. 12, 13, 15
• If a scheduled dose is missed, the omitted dose should be given as soon as possible without restarting the series. 12, 13

Post‑Exposure Prophylaxis (PEP)

• Sexual contacts of individuals with acute hepatitis B should receive hepatitis B immune globulin (HBIG) and begin the vaccine series within 14 days, irrespective of pregnancy status. 12, 13
• Combined HBIG + vaccine PEP is more effective than vaccine alone for preventing infection after exposure. 12, 13
• Pregnancy does not modify the standard PEP protocol; the same regimen applies to pregnant individuals. 12, 13

Breastfeeding

• Hepatitis B vaccination is not contraindicated for breastfeeding individuals; the vaccine can be administered safely while lactating. 16

Clinical Pitfalls to Avoid

• Do not postpone vaccination in pregnant individuals at risk due to unfounded safety concerns; the vaccine is explicitly safe during pregnancy. 12, 13, 14, 15
• Do not give the vaccine in the buttock, as this significantly lowers immunogenicity in adults. 12, 13, 15
• Do not restart the vaccination series if a dose is missed; simply administer the missed dose promptly. 12, 13
• Do not withhold HBIG and vaccine from pregnant individuals requiring PEP; the 14‑day window for initiation remains critical. 12, 13