Is the rabies vaccine (inactivated vaccine) safe for pregnant women to receive if they are at risk of rabies exposure?

Rabies Vaccine Safety in Pregnancy

Yes, babies born to women who received rabies vaccine during pregnancy were normal, and the inactivated rabies vaccine is safe for pregnant women to receive for both post-exposure and pre-exposure prophylaxis when indicated. 1

Post-Exposure Prophylaxis: Always Administer

Pregnancy is never a contraindication to rabies post-exposure prophylaxis, and the vaccine must be given immediately following any potential rabies exposure. 2, 1

• Rabies has a nearly 100% case fatality rate once clinical symptoms develop, making the theoretical risks of vaccination negligible compared to the consequences of untreated exposure 2, 1
• No increased risk of adverse pregnancy outcomes (including abortion, premature births, or fetal abnormalities) has been documented following post-exposure rabies vaccination 2, 1
• Standard dosing and vaccination schedules should be followed without modification during pregnancy 1

Supporting Evidence from Clinical Studies

• A study of 29 pregnant women who received purified vero cell rabies vaccine (PVRV) showed no adverse vaccine effects, normal intrauterine growth on ultrasound, satisfactory pregnancy outcomes, and no congenital anomalies in any infants during one-year follow-up 3
• Another series of 21 pregnant women receiving post-exposure vaccination (12 also receiving equine rabies immune globulin) reported only mild, transient side effects (15% experienced myalgia, malaise, or local reactions), with no rabies cases in mothers or infants and no congenital malformations detected 4
• A follow-up study of 14 pregnant women receiving modern rabies vaccines and equine rabies immunoglobulin reported zero adverse events, with all women having safe vaginal deliveries and healthy, normal children 5

Pre-Exposure Prophylaxis: Consider for High-Risk Women

Pre-exposure prophylaxis may be administered during pregnancy when there is substantial risk of rabies exposure. 2, 1

• The safety demonstrated in post-exposure studies supports pre-exposure use for pregnant women at high risk 2, 1
• The inactivated virus platform used in rabies vaccines is inherently safer in pregnancy compared to live attenuated vaccines 1
• Risk assessment should focus on likelihood of exposure (e.g., veterinarians, animal handlers, travelers to endemic areas, laboratory workers) 1

Critical Clinical Pitfall: Vaccine Hesitancy

A major preventable cause of rabies deaths in pregnant women is fear-based refusal of post-exposure prophylaxis due to misconceptions about fetal safety. 6

• During 2015-2016 in Vietnam, four pregnant women and two breastfeeding mothers died from rabies after dog bites; none sought PEP, with families reporting fear of risk to the fetus or breastfed child as the primary barrier 6
• Three of the four pregnant women had cesarean deliveries in attempts to save the babies, with tragic outcomes 6
• This underscores the critical need for clear communication that rabies PEP has no known contraindications and is safe during pregnancy 1, 6

Mother-to-Child Transmission Risk

• Mother-to-child transmission of rabies is possible but extremely rare, as rabies virus is not present in blood and fetal exposure to maternal infectious fluids appears limited 7
• Infants born to mothers with rabies should receive post-exposure prophylaxis (including rabies immune globulin and vaccine) as soon as possible as a conservative approach 7
• Both cesarean section and vaginal delivery have resulted in healthy infants when appropriate PEP was administered 7

Clinical Decision Algorithm

For any pregnant woman with potential rabies exposure:

1. Administer complete post-exposure prophylaxis immediately, regardless of pregnancy status 1
2. Use standard dosing without modification 1
3. Include rabies immune globulin for appropriate exposures 4, 5
4. Counsel that the vaccine is safe with extensive evidence of normal pregnancy outcomes 2, 1, 3

For pre-exposure prophylaxis consideration:

1. Assess occupational or travel-related exposure risk 1
2. If substantial risk exists, administer pre-exposure vaccination despite pregnancy 1
3. Use the same inactivated vaccine platform proven safe in post-exposure studies 2, 1