Nothing, perhaps, raises as much anxiety in the heart of a medical provider as the prospect of having to give immunizations to a pregnant woman.  We have assembled here and in the accompanying pages references from the recent medical literature that are pertinent to this matter.  On this page are references to vaccination in general during pregnancy.  Specific vaccines are discussed on their references presented on other pages.

On the whole, the medical literature is reassuring and supportive.  Aside from scattered case reports, there are no currently available vaccines that have been definitely demonstrated to be teratogenic or to have other adverse fetal or maternal effects.  In addition, earlier reports of a lack of immune response to vaccination during pregnancy have been followed by subsequent studies that seem to show adequate immune protection even if measurable titers are not always as high during pregnancy.

As we have pointed out in the patient-oriented pages of this web site, our practice is to be as patient-specific and itinerary-specific as possible in recommending vaccines during pregnancy.  Where a change in itinerary will avoid exposure to disease, or where a written waiver will suffice for political requirements, we advocate this approach.

There are instances, however, when the trip cannot be altered or postponed and disease exposure is highly likely or inevitable.  In these instances, given the available data on both the vaccines and the diseases they present, it is almost always the case that the vaccine presents less of a risk than the disease.  Having carefully advised the patient of these facts, we will then obtain proper written consent and offer the vaccine.

Below is a list of general references on the topic of vaccination during pregnancy.

1. ACOG Technical Bulletin #160—Immunization During Pregnancy

2. Obstet Gynecol 2003 Jan;101(1):207-12  ACOG Committee Opinion. Immunization during pregnancy.

3. Gonik B, Jones T, Contreras D, Fasano N, Roberts C. The obstetrician-gynecologist's role in vaccine-preventable diseases and immunization. Obstet Gynecol 2000 Jul;96(1):81-4 OBJECTIVE: To assess by survey the immunization role currently played obstetrician-gynecologists in the state of Michigan. METHODS: Masked questionnaires requesting demographic, knowledge-based, practice, and attitudinal data were sent to 850 ACOG-registered fellows. RESULTS: Three hundred sixty-five physicians responded, 313 of whom were in active practice. Most were male (70%) and graduated from medical school between 1970 and 1989 (68%). The majority provided both obstetric and gynecologic services. The minority (47%) specifically identified themselves as primary care providers. Only 15% of respondents considered screening for vaccine-preventable diseases to be outside the realm of routine obstetric-gynecologic care. In practice, however, 19% did not screen their obstetric patients for any vaccine-preventable diseases, and only 10% assessed their patients for all nine vaccine-preventable diseases listed in the questionnaire. In gynecologic patients, almost 40% of physicians did not assess for any vaccine-preventable disease. A wide range in knowledge level was identified concerning vaccine-preventable diseases, immunization recommendations, and vaccine safety. CONCLUSION: These data show a discrepancy between perceived responsibilities and actual practice patterns of obstetrician-gynecologists regarding vaccine-preventable diseases and the immunization of women. Limitations in current knowledge and practical concerns specific to vaccine administration contribute to this disparity.

4. Sprabery LR. Vaccinations in women. Obstetrics and Gynecology Clinics, Volume 28 • Number 2 • June 2001
5. Munoz FM, Englund JA. Vaccines in Pregnancy. Infectious Disease Clinics of North America, Volume 15 • Number 1 • March 2001. Neonates and young infants are susceptible to significant morbidity and mortality caused by bacterial and viral pathogens. Maternal antibodies transmitted transplacentally before birth confer protection against viral and bacterial diseases that are often serious in the first months of life.  In general, active immunization has not been successful in this age group because of the immaturity of the immune response, the length of time required to develop protective immunity, and interference of maternally derived antibodies. Furthermore, the safety of administering vaccines in young infants remains a concern and requires careful evaluation. New technological advances in the development of safer and effective vaccines, along with information collected in recently conducted studies, make maternal immunization a plausible option for the prevention of life-threatening diseases in this vulnerable population.
6. Fischer GW, Ottolini MG, Mond JJ. Prospects for vaccines during pregnancy and in the newborn period. Clin Perinatol 1997 Mar;24(1):231-49. Maternal and neonatal vaccine strategies have been used successfully throughout the world for many years. In addition, new vaccine technologies are likely to overcome the scientific issues related to safety, immunogenicity, and efficacy of neonatal vaccines. There are obvious advantages to maternal or neonatal immunizations. Immunologic protection in the first 8 to 12 weeks of life occurs only by passive immunization with IgG or by actively immunizing the mother or newborn baby (or by doing both as in hepatitis B). Although mothers may have protective levels of antibody to many pathogens, only active immunization of mothers or babies ensures that reliable protective levels are abundant in the neonate. Also, premature infants receive lower levels of passive maternal antibody and may not be protected regardless of maternal levels of specific antibodies. Thus, there is a particular need for development of neonatal immunization strategies in these babies. There is another value of neonatal immunization in the newborn period and that is compliance. In all areas of the world there is often poor compliance with infant vaccination policies. The newborn period offers the earliest possible time at which many infants can be reliably started on their immunization program. In many parts of the developing world this is already being put into practice for selected vaccines. Many of the vaccines currently used or under consideration for maternal or neonatal immunization are listed in Table 4. What are the impediments to progress in this area? For neonatal immunization there are several issues; however, the main impediment is providing vaccines that are safe, provide rapid protection, and are highly immunogenic if given to babies with an immature immune system. As reviewed in this article, current vaccines are safely and effectively used in newborn babies. As new vaccine technologies improve immunogenicity and allow mucosal delivery, the routine childhood immunization may move into the newborn period. Maternal immunization is a more complex issue. Currently available vaccines and new conjugate vaccines are immunogenic in women, and there is no convincing evidence of risk to the fetus by immunizing pregnant women with bacterial vaccines, toxoids, or inactive viral vaccines. The reduction in anti-PRP antibody in mothers receiving PRP-T conjugate vaccine within 4 weeks of a tetanus shot, however, demonstrates the necessity to demonstrate immunogenicity, safety, and efficacy of maternal immunization strategies before universal implementation. To hasten the availability and utilization of maternal vaccines, an increasing emphasis on research with increased funding should focus on vaccine development specifically to provide protection for infants in the first weeks of life (both maternal and neonatal vaccine strategies). The pharmaceutical industry, physicians, and the FDA must work together to develop guidelines for studies that will efficiently analyze the safety and efficacy of candidate vaccines. Liability issues also must be addressed so that physicians and the pharmaceutical industry can become comfortable with producing and employing vaccines that will protect babies at the earliest possible time.
7. Ebbert GB, Mascolo ED, Six HR. Overview of vaccine manufacturing and quality assurance. [Chapter 4]. In: Plotkin SA, Orenstein WA, eds. Vaccines. 3rd ed. Philadelphia, PA: W.B. Saunders, 1999;815–79.
8. Stirrat GM,  Pregnancy and immunity. Editorial. BMJ 1994 May 28;308(6941):1385-6
9. Lee S.  Pregnancy and Immunity – Comment on (above).  BMJ 1994 Jul 9;309(6947):130