What vaccinations are recommended during pregnancy?

Vaccination During Pregnancy

All pregnant women should receive the inactivated influenza vaccine during any trimester and the Tdap vaccine between 27-36 weeks of gestation in every pregnancy, as these are the two routinely recommended vaccines that protect both mother and infant from severe disease and mortality. 1, 2

Routinely Recommended Vaccines for All Pregnant Women

Influenza Vaccine

• Administer one dose of inactivated influenza vaccine during any trimester of pregnancy. 1, 2
• The CDC and WHO prioritize pregnant women for seasonal influenza vaccination because they face 7.2% higher hospitalization rates and disproportionately high mortality risk compared to non-pregnant women. 1
• Influenza infection during pregnancy increases risk of late pregnancy loss (adjusted hazard ratio 10.7; 95% CI 4.3-27.0) and reduces infant birthweight. 1
• The inactivated trivalent or quadrivalent vaccine is safe; the live attenuated nasal spray formulation is contraindicated. 2, 3

Tdap Vaccine (Tetanus, Diphtheria, Pertussis)

• Administer one dose between 27-36 weeks of gestation in every pregnancy, with optimal timing at 27-28 weeks. 1, 2, 4
• This timing maximizes maternal antibody response and passive antibody transfer to protect infants in the first 3 months of life when pertussis mortality risk is highest. 2, 5
• If not given during pregnancy, administer immediately postpartum. 1, 2
• For wound management during pregnancy, use Tdap instead of Td if ≥5 years since previous booster. 2

COVID-19 Vaccine

• Administer during any trimester of pregnancy and up to 6 months postpartum if not vaccinated during pregnancy. 4
• mRNA vaccines have initial safety data supporting their use in pregnant women. 1

RSV Vaccine

• Administer RSVPreF between 24-36 weeks of gestation, preferably between 32-36 weeks. 4

Vaccines for High-Risk Situations

These vaccines should be administered when specific risk factors are present:

• Hepatitis B: Recommended for pregnant women at risk for hepatitis B virus infection. 1, 2
• Hepatitis A: Consider for women at increased risk. 1
• Pneumococcal polysaccharide: Consider for women at increased risk. 1
• Meningococcal conjugate or polysaccharide: Consider for women at increased risk; pregnancy should not preclude use when otherwise indicated. 1, 2
• Yellow fever: Administer to pregnant women traveling to high-risk areas, as infection risk outweighs theoretical vaccination risks. 1, 2
• Inactivated polio (IPV): Can be administered to pregnant women at risk for wild-type poliovirus exposure. 1
• Rabies: Not contraindicated for post-exposure or pre-exposure prophylaxis when substantial risk exists, as rabies has nearly 100% mortality. 6

Absolutely Contraindicated Vaccines

Live attenuated vaccines are contraindicated during pregnancy due to theoretical risk of placental transmission and fetal infection. 1, 2, 3

These include:

• MMR (measles, mumps, rubella) 1, 2, 7
• Varicella (chickenpox) 1, 2, 7
• Live attenuated zoster vaccine (Zostavax) 2
• Smallpox (vaccinia) - the only vaccine known to cause actual harm to the fetus 1, 2
• Live attenuated influenza vaccine (nasal spray) 2, 7
• BCG 7

Vaccines to Delay Until After Pregnancy

• HPV vaccine: Should be delayed until after pregnancy as a precautionary measure, though not an absolute contraindication. 2, 3
• Recombinant zoster vaccine (Shingrix): Should be delayed until after pregnancy if indicated. 2

Critical Clinical Considerations

Pre-Pregnancy Planning

• Evaluate all women of childbearing age for immunity to rubella and varicella before pregnancy. 8
• Administer MMR vaccine to susceptible women, then advise avoiding pregnancy for 4 weeks after vaccination. 1, 8, 3
• No cases of congenital abnormalities have been documented among infants born to women inadvertently vaccinated during pregnancy, but the precaution remains. 1, 8

Postpartum Vaccination

• Administer MMR and varicella vaccines immediately postpartum to susceptible women. 8, 3
• Give Tdap, influenza, and HPV vaccines postpartum if not administered during pregnancy. 3

General Safety Principles

• Inactivated, recombinant, subunit, polysaccharide, conjugate vaccines and toxoids pose no risk during pregnancy. 1
• No evidence exists of risk from vaccinating pregnant women with inactivated virus or bacterial vaccines or toxoids. 1
• Benefits of vaccinating pregnant women usually outweigh potential risks when disease exposure likelihood is high and infection would pose risk to mother or fetus. 1

Common Pitfalls to Avoid

• Do not delay influenza vaccination to a specific trimester - it can and should be given at any time during pregnancy. 1, 2
• Do not miss the optimal 27-36 week window for Tdap - this timing is critical for infant protection. 2, 4
• Do not administer smallpox vaccine to household contacts of pregnant women - this is the only vaccine that poses risk through contact exposure. 1
• Do not assume routine pregnancy testing is needed before live virus vaccines - simply ask about pregnancy status and counsel accordingly. 1
• Do not assume women born before 1957 are immune to measles - up to 9.3% may be susceptible. 8

Addressing Vaccine Hesitancy

Current vaccination coverage remains suboptimal, with only 61.2% of pregnant women in the US receiving influenza vaccine. 1, 2 Healthcare providers should proactively recommend vaccines, emphasizing that maternal immunization protects both mother and infant through passive antibody transfer and prevention of maternal infection. 4, 5, 9