What vaccine is recommended for a patient planning to get pregnant during the preconception period?

Preconception Vaccination Recommendations

All four vaccines listed (rubella, pertussis, influenza, and varicella) are recommended during the preconception period, but rubella and varicella are specifically prioritized because they are live vaccines that must be given before pregnancy, not during. 1, 2, 3

Live Vaccines Required Before Pregnancy

Rubella and Varicella (Options A and D)

• These live attenuated vaccines are contraindicated during pregnancy and must be administered during preconception counseling. 1, 4
• The American College of Obstetricians and Gynecologists explicitly states that preconceptional vaccination of women to prevent disease in offspring is preferred to vaccination during pregnancy when practical. 1
• Women should be evaluated for immunity to rubella and varicella, and if susceptible, should be vaccinated immediately with a recommendation to avoid pregnancy for at least 28 days after vaccination. 1, 2
• Rubella vaccination during preconception prevents congenital rubella syndrome in the fetus, which can cause severe birth defects. 3
• Varicella vaccination prevents maternal infection that could lead to congenital varicella syndrome. 1, 3

Vaccines That Can Be Given During Pregnancy

Influenza (Option C)

• Influenza vaccine is recommended during pregnancy at any trimester, making it less specific to the preconception period. 1, 5, 6
• While it can be given during preconception, it is not uniquely required at this time since it remains safe and indicated throughout pregnancy. 1, 7
• The inactivated influenza vaccine should be administered annually, ideally before flu season (October-November). 1, 6

Pertussis/Tdap (Option B)

• Tdap is routinely recommended during pregnancy between 27-36 weeks gestation, not specifically during preconception. 1, 7
• While Tdap can be given during preconception if a woman hasn't received it within 10 years, the current strategy prioritizes administration during each pregnancy to maximize passive antibody transfer to the infant. 1
• The preconception strategy of vaccinating women before pregnancy is considered less optimal than the current recommendation of vaccination during the third trimester of each pregnancy. 1

Clinical Algorithm for Preconception Vaccination

Step 1: Check immunity status

• Test for rubella and varicella immunity through serology. 1, 2

Step 2: Administer live vaccines if non-immune

• Give MMR (covers rubella) and/or varicella vaccine if no evidence of immunity. 1, 2, 3
• Counsel patient to avoid pregnancy for 28 days after live vaccine administration. 1

Step 3: Update other vaccines as indicated

• Administer Tdap if not received within past 10 years (though will be repeated during pregnancy). 1
• Offer influenza vaccine if during flu season. 1, 7
• Consider hepatitis B vaccine series if at risk and not previously vaccinated. 1, 3

Critical Distinction

The key differentiator is that rubella and varicella are the only vaccines among the options that are contraindicated during pregnancy, making preconception the essential window for administration. 1 Influenza and pertussis vaccines can safely be given during pregnancy, so while they may be offered during preconception, they are not uniquely required at this time. 1

Common Pitfall

• Providers sometimes delay rubella and varicella vaccination assuming they can be given during pregnancy—this is incorrect and represents a missed opportunity for disease prevention. 1, 4
• Approximately 50% of pregnancies in the United States are unplanned, making routine preconception vaccination of all women of childbearing age critical. 1