What is the recommended tetanus toxoid (TT) vaccination schedule in pregnancy?

Tetanus Toxoid Vaccination in Pregnancy

Primary Recommendation

All pregnant women should receive Tdap vaccine between 27-36 weeks gestation during each pregnancy, regardless of prior vaccination history, to prevent neonatal pertussis and tetanus. 1, 2, 3

Standard Vaccination Schedule for Pregnant Women

For Women with Complete Primary Series

• Administer one dose of Tdap between 27-36 weeks gestation during every pregnancy, even if Tdap was received in a previous pregnancy or recently outside of pregnancy 1, 2, 4
• Vaccinate as early as possible within the 27-36 week window (ideally 27-30 weeks) to maximize maternal antibody response and passive transfer to the infant 1, 5
• This timing ensures at least 2 weeks for maximal immune response before delivery and coincides with the period when active IgG transport across the placenta becomes substantial (after 30 weeks) 5
• Maternal Tdap vaccination during this window is 80-91% effective in preventing infant pertussis 5

For Women with Unknown or Incomplete Tetanus Vaccination

Begin the primary series immediately upon recognition, regardless of gestational age—do not delay waiting for an "optimal" trimester. 1, 2

• First dose: Administer as soon as feasible when the vaccination gap is identified 2
• Second dose: At least 4 weeks after the first dose 1, 2
• Third dose: 6 months after the second dose 1, 2
• Td is preferred for the primary series, but substitute one dose with Tdap, preferably between 27-36 weeks gestation 1, 2
• The urgency stems from preventing maternal and neonatal tetanus, which carries significant morbidity and mortality risk 2

Special Circumstances Requiring Immediate Vaccination

Wound Management During Pregnancy

• If ≥5 years have elapsed since the last tetanus booster, administer Tdap immediately regardless of gestational age—do not delay for optimal timing windows 1, 2, 5
• For contaminated or tetanus-prone wounds in women with incomplete primary series, administer both Tdap and tetanus immune globulin (TIG) 250 units IM in separate syringes at different anatomic sites 1

Tetanus Booster Due (>10 Years Since Last Td)

• Administer Tdap between 27-36 weeks gestation if a routine tetanus booster is indicated 1, 5

Critical Pitfalls to Avoid

• Do not delay the first dose in unvaccinated pregnant women waiting for the "optimal" trimester—maternal and neonatal tetanus prevention takes priority over timing preferences 2
• Do not assume vaccination history is complete without documentation—treat uncertain histories as unvaccinated 1, 2
• Do not skip Tdap during pregnancy even if the woman received it recently outside of pregnancy—each pregnancy requires Tdap at 27-36 weeks 1, 2, 5
• Do not restart the series if doses are delayed—simply continue from where the patient left off 2
• Do not administer tetanus boosters more frequently than every 5 years during pregnancy to avoid Arthus-type hypersensitivity reactions 1, 3

Safety Considerations

• Inactivated vaccines like Tdap are safe during pregnancy with no evidence of adverse fetal effects 4, 6
• Experience with tetanus toxoid-containing vaccines suggests no excess risk for severe adverse events when Tdap is given with every pregnancy 5
• Tdap may be safely given at any time during pregnancy if needed for wound management, pertussis outbreaks, or other extenuating circumstances 4, 6

Postpartum Vaccination

• If Tdap was not administered during pregnancy, give it immediately postpartum for women who have never received Tdap 1, 5

Product Selection

• When feasible, Boostrix should be used for pregnant women, though either Tdap product (Boostrix or Adacel) is acceptable 3