1. Vaccines and Pregnancy
관동대학교 제일병원 산부인과
한국 마더리스크 프로그램
안 현경

2. Goals
 Routinely recommended immunization in pregnancy
 Contraindications and precautions
 High risk groups for selective immunization

3. Effectiveness of Vaccines
 Prevent disease from occurring
 Reduce morbidity and mortality if disease acquired

4. Effectiveness of Vaccines
Measles, 1950 – 2001, USA Rubella, 1966 – 1997, USA

5. Objectives of Maternal Vaccination
 Protects both the mother and fetus from the morbidity
 Provide the infant passive protection
 Passive immunity by trans-placental transfer of antibodies
 Vaccinating pregnant women in third trimester for influenza
 63% decreased incidence of lab-confirmed influenza in infant
 Decreased respiratory illness 36% within first 6 months of life
Zaman K et al, 2008

6. Vaccine recommendations in Pregnancy
by ACIP(Advisory committee on immunization practice)
 Vaccines
 Recommended
 Consider if otherwise indicated
 Recommended to avoid
ACIP:

7. Types of Immunization
 Live vaccines (Varicella, MMR, Zoster, LAIV)
 Potential for infecting fetus
 No harm ever reported
 Discouraged unless at high risk for exposure and suboptimal
morbidity/mortality from infection
 If pregnancy occurs within 4 weeks of immunization
 Counsel woman on theoretical risk
 Termination : Not indicated

8. Types of Immunization
 Toxoids, inactivated vaccines, immune globulin preparations
 Considered safe
 Wait until 2nd trimester (except flu)
 Fetal development
 Adverse first trimester events (miscarriage, birth defects)

9. Vaccine General Recommendation for Use in Pregnant Women
Hepatitis A Recommended if otherwise indicated.
Hepatitis B Recommended in some circumstances.
Human Papillomavirus (HPV) Not recommended.
Influenza (Inactivated) Recommended.
Influenza (LAIV) Contraindicated.
MMR Contraindicated.
MCV4 (MenACWY) May be used if otherwise indicated.
PCV13 Inadequate data for specific recommendation.
PPSV23 Inadequate data for specific recommendation.
Polio May be used if needed.
Td Should be used if otherwise indicated.
Tdap Recommended.
Varicella Contraindicated.
Zoster Contraindicated.
Guidelines for Vaccinating Pregnant Women by CDC

10. Timing of maternal immunization
 Pre-conception counseling on immunizations is ideal
 Prenatal counseling
 High risk of exposure
 Infection would be hazardous to mother or fetus
 Immunizing agent if benign

11. Preconception vaccination
 R/O pregnancy
 By history
 In next 4 weeks
 No difference in outcomes in becomes pregnant

12. Preconception vaccination
 HPV
 Women up to 26years
 If becomes pregnant delay remainder of regimen

13. Preconception vaccination
 MMR
 Measles
 More serious measles infection, higher risk of complications
 Preterm birth, low birth weight, and miscarriage
 no definite evidence of a higher rate of birth defects among offspring
of infected gravida
 Mumps
 Miscarriage and fetal death in first trimester
 Endocardial fibroelastosis

14. Preconception vaccination
 Rubella
 Miscarriage and fetal death
 Congenital rubella syndrome
 hearing loss, cataracts, cardiac abnormalities, bone lesions, growth
restriction, and neurologic abnormalities including intellectual
disability
 Document immunity via IgG

15. Preconception vaccination
 Varicella
 congenital varicella syndrome
 limb hypoplasia, microcephaly, dermal scarring, ocular defects
 2 percent of fetuses infected in first 20 weeks of gestation
 9 cases : 20 and 28 weeks of gestation
 In utero exposure to maternal varicella
 Herpes zoster in infancy or early childhood

16. Antenatal vaccination
 Benefits to both mother and fetus should outweigh the risks
 Live vaccines should be avoided during pregnancy
 Minimize their risk of exposure to infections
 avoiding travel to high risk locations
 Household members are immunized
 Maintaining good hygienic practices

17. Tetanus
 Infection caused by ClostridiumTetani. Found in soil, dust, and animal feces
 Enters in body by puncture wounds, splinters, insect bites, burns etc.
 Causes uncontrollable muscle spasms, Bacteria binds to motor nerve, spinal
cord and brain stem leading to lock jaw, coma and DEATH!!!

18. Tetanus Vaccine
 Vaccine given to infants at 2 months, 4 months, and 6 months.
 Children get a booster at 4 or 5 years of age prior to school.
 Additional booster given at age 12.This should be aTdap.
 Continued boosters every 10 years or every 5 year if puncture
wound/burn

19. Antenatal vaccination
 Pertussis
 Bordetella pertussis.
 Life threatening to newborns and infants
 May start as a runny nose, low grade fever or cough.
 Immunity wanes and disease is increasing
 House members can transmit, especially mothers (50%)
 Tdap during each pregnancy, optimally between 27 and 36 weeks of
gestation

20. Recommendation of Tdap
 No, incomplete, or unknown immunization against tetanus and diphtheria
 Start or complete the series at 0, 4 weeks and 6-12months
 A dose ofTdap should replace one of theTd doses
 Between 27 and 36 weeks of gestation.
 Td immunization complete and up to date
 Tdap at 27 to 36 weeks of gestation
 More than 5 or 10 years since lastTd booster
 Tdap at 27 to 36 weeks of gestation

21. Antenatal vaccination
 Influenza
 Serious morbidity / mortality in pregnant and postpartum women
 Vaccination
 Reduce risk of medical and pregnancy complication
 Provides passive protection to the neonate
 Inactivated influenza vaccine in October or the first half of November
 Regardless of gestational age

22. Selective immunization of high risk groups
 Occupation, habits, travel plans, or the area in which they reside
 No immunization is more harmful than the disease

23. Hepatitis B
selective immunization
 Recombinant vaccine
 Complete a series
 High risk women
 Sexually active individuals and/or partner
 Intravenous drug users
 Healthcare workers
 Having a hepatitis B Ag-positive sex partner

24. Hepatitis A
selective immunization
 Preterm delivery
 In utero infection
 Meconium peritonitis, fetal ascites, and polyhydramnios
 Can give passive immunization with immune globulin for postexposure
prophylaxis

25. Other disease
selective immunization
 Pnemococcus : Give after 1st trimester
 Yellow fever : mosquito-borne viral hemorrhagic fever
 South America and sub-Saharan Africa
 Avoid travel
 Yellow fever vaccine can cause serious adverse effects in the mother
 Poliovirus
 Haemophilus influenza: Give for prior splenectomy
 Meningococcal

26. Other diseases
selective immunization
 Typhoid:Travel
 Small pox: Live virus vaccine
 Not recommended
 Rabies
 Give if exposed
 Cholera, plague, Japanese encephalitis
 Give if high risk of exposure
 Tuberculosis
 Not recommended

27. Postpartum vaccination
 Both inactivated and live vaccines( except smallpox and yellow fever) are
safe for lactating mothers
 Two vaccines that should be given before discharge to protect mother and
newborn
 MMR
 Varicella
 Tdap

28. Summary and Recommendation
 Nonpregnant women of childbearing age who may become pregnant
 Clinically indicated immunizations at least one month prior to
conception
 Before administering any vaccine,
 if she is pregnant or could become pregnant in the next four weeks and
counseling her about the potential risks of vaccination during pregnancy
or just before conception.
 During influenza season
 Influenza vaccination regardless of trimester of pregnancy

29. Summary and Recommendation
 Pregnant women should minimize their risk of exposure to infections
 Avoiding travel to high risk locations
 Immunization of household members
 Maintaining good hygienic
 Pregnancy within 1month of immunization with the live vaccine
 Termination of pregnancy for this indication is unwarranted.
 Toxoids, inactivated virus vaccines, or immune globulin preparations
 Conception

30. Summary and Recommendation
 MMR and varicella vaccines
 Postpartum women who are breastfeeding
 Tdap
 Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine
 All pregnant women in each pregnancy between 27 and 36 weeks of
gestation
 Passive immunity 2 to 6 months

31. 감사합니다.

32. Recommended adult immunization
schedule
2013 USA

33. Recommended vaccinations indicated for
adults based on medical and other
indication 2013, USA