What are the guidelines for administering Tdap (tetanus, diphtheria, and pertussis) vaccine in pregnancy?

Guidelines for Tdap Vaccination During Pregnancy

Every pregnant woman should receive one dose of Tdap vaccine during each pregnancy, regardless of prior Tdap vaccination history, optimally between 27-36 weeks gestation to maximize maternal antibody transfer to the infant. 1

Timing of Tdap Administration

• Optimal timing: 27-36 weeks gestation, preferably during the earlier part of this window 1

• Administering earlier within this window maximizes:

  • Maternal antibody response
  • Passive antibody transfer to the infant
  • Antibody levels in the newborn 2

• A minimum of 2 weeks is required after vaccination to mount a maximal immune response 1

• Active transport of maternal immunoglobulin G does not substantially occur before 30 weeks gestation 1

Special Situations

Wound Management in Pregnancy

• If tetanus prophylaxis is indicated for wound management (>5 years since last tetanus toxoid-containing vaccine):
  • Tdap should be used instead of Td for pregnant women 1
  • This applies regardless of timing during pregnancy

Pregnant Women with Incomplete/Unknown Tetanus Vaccination

• For women never vaccinated against tetanus:
  • Complete series of three tetanus and diphtheria toxoid-containing vaccines
  • Schedule: 0,4 weeks, and 6-12 months
  • Tdap should replace 1 dose of Td, preferably at 27-36 weeks gestation 1

Pregnant Women Due for Tetanus Booster

• If a tetanus booster is indicated during pregnancy (>10 years since previous Td):
  • Administer Tdap instead of Td
  • Optimal timing remains 27-36 weeks gestation 1

If Tdap Not Given During Pregnancy

• For women not previously vaccinated with Tdap:
  • Administer Tdap immediately postpartum if not given during pregnancy 1

Safety Considerations

• No evidence of adverse fetal effects from vaccinating pregnant women with inactivated vaccines or toxoids 2
• Growing body of data demonstrates safety of Tdap use in pregnancy 2
• Common reactions include local injection site reactions (pain, soreness, swelling, redness) 3
• Approximately 67% of women experience at least one reaction to vaccination, though most state the vaccine is well-tolerated 3

Cocooning Strategy

• In addition to maternal vaccination, ACIP recommends that adolescents and adults who have or anticipate close contact with infants <12 months (parents, siblings, grandparents, caregivers) receive Tdap if not previously vaccinated 1

Common Pitfalls to Avoid

1. Delaying vaccination beyond the optimal window - While Tdap may be given at any time during pregnancy, waiting until after 36 weeks may not allow sufficient time for antibody development and transfer
2. Skipping vaccination due to prior Tdap receipt - Current guidelines clearly recommend Tdap during EACH pregnancy regardless of prior vaccination history
3. Using Td instead of Tdap - For pregnant women, Tdap should always be used when a tetanus-containing vaccine is indicated
4. Missing postpartum vaccination - If Tdap was not given during pregnancy and the woman has never received Tdap, immediate postpartum vaccination is recommended

Vaccination coverage during pregnancy has increased substantially from <1% before 2009 to approximately 54% by 2015 4, but there remains room for improvement in implementing these guidelines to protect vulnerable infants from pertussis.