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2015;17:25763
Review
Vaccination in pregnancy
P S Arunakumari
a,
* Sujatha Kalburgi
b
MBBS,
Amita Sahare
MD MRCOG
Consultant Obstetrician and Gynaecologist, Basildon and Thurrock University Hospitals NHS Foundation Trust, Nethermayne, Basildon SS16
5NL, UK
b
Specialty Trainee in Obstetrics and Gynaecology, Basildon and Thurrock University Hospitals NHS Foundation, Nethermayne, Basildon SS16
5NL, UK
*Correspondence: P S Arunakumari. Email: ps.arunakumari@btuh.nhs.uk
Key content
Please cite this paper as: Arunakumari PS, Kalburgi S, Sahare A. Vaccination in pregnancy. The Obstetrician & Gynaecologist 2015;17:25763.
Introduction
One of the greatest triumphs of immunology has been the
development of vaccines against certain infectious agents.1
Vaccination is one of the most successful and cost-effective
public health interventions; it has led to the eradication of
some diseases (smallpox) and the control of many others
(polio and whooping cough).2
Maternal vaccination protects both the mother and fetus
from the morbidity of certain vaccine-preventable diseases.
Principles of immunology
The human host is endowed with defence mechanisms to
protect the body against foreign environmental agents.
Induction of immunity
Immunity is defined as resistance to disease, specifically
infectious disease. Immunity may be induced in an individual
by infection or immunisation. Active immunisation involves
the administration of an antigen to stimulate production of
antibodies. Passive immunity involves the administration of
an antibody to confer short-term immunity.
Passive immunity
Passive immunity is useful for rapidly conferring immunity
even before the individual is able to mount an active
response but it does not induce long-lived resistance to
infection.3 The only physiological example of passive
immunity is seen in the neonatal period, where despite
immaturity of the immune system the neonate is protected
against infection by passively transferred antibodies from the
mother through the placenta and the breast milk. Placentallyderived antibodies are of the type IgG. The major
immunoglobulin in milk is IgA. This is not absorbed by
the baby but remains in the intestine to protect the mucosal
surfaces; this maternal antibody attenuates many infections,
allowing neonatal cellular immunity to mature under
controlled conditions.4
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Vaccination in pregnancy
Adaptive immunity
Phylogenetically older
Less specialised
Less powerful
First line of defence
Poor specicity, antigen nonspecic
Rapid response, usually within minutes
Does not react against the host
No memory
Components include epithelial barriers, phagocytes - neutrophils,
monocytes and macrophages
Evolved later
More specialised
More powerful
Subsequent line of defence
High specicity, antigen specic
Slow response, takes days
Can react against the host
Memory evident
Components include lymphocytes (T and B cells)
and their products: antibodies and cytokines
Immunology of pregnancy
During normal pregnancy, the maternal immune system
adapts to accommodate the semi-allogenic fetal graft. This is
essential for the acceptance of the fetus and the development
of the placenta without compromising the integrity of the
maternal host. Nevertheless, this modulation of the maternal
immune system is generally not believed to cause a substantial
difference in the immune response to vaccination.5
Vaccination
Vaccination is the process of stimulating a protective
adaptive immune response against microbes by exposure to
nonpathogenic forms or components of the microbes.3
A vaccine is a biological preparation that improves
immunity to a particular disease. Most vaccines generate
antibodies that prevent the damage caused by toxins or that
neutralise the pathogen. Vaccines work by inducing active
immunity and by providing immunological memory.
Immunological memory allows the immune system to
recognise and respond rapidly to natural infection when
exposed at a later stage; this prevents or modifies the effect of
the disease.6
Types of vaccines
Vaccines can be broadly divided into live vaccines, killed
vaccines and purified macromolecules derived from
pathogens (Figure 1, Table 2).
Live vaccines
Attenuated vaccines utilise microbes that have been treated to
abolish their infectivity and pathogenicity yet still retain
their antigenicity.
With live viral vaccines there is a possibility that the viral
nucleic acid may be incorporated into the host genome or
that there might be a reversion to a virulent form. Further,
live vaccines have the potential to infect the fetus. For these
reasons, use of live vaccines is generally contraindicated
258
Killed vaccines
Often the immunity conferred by inactivated vaccines is
inferior to that resulting from live vaccines. This is because
the replication of the living microbes confronts the host with
a larger and more sustained dose of antigen. Furthermore, as
these preparations are often injected, the immune response
does not take place at the site of natural infection.
Purified macromolecules
Three general forms of purified macromolecule vaccines are
in current use:
inactivated toxins
conjugate vaccines
subunit vaccines.
Bacterial toxins can be detoxified by formaldehyde
treatment and used to stimulate immunity. Examples
include diphtheria toxoid and tetanus toxoid.
Conjugate vaccines or carbohydrate vaccines are
polysaccharides. As the glycans tend to be poorly
immunogenic, they are conjugated to a carrier protein to
increase their immunogenicity. Examples include
Haemophilus influenzae vaccine, Neisseria meningitidis
vaccine and Streptococcus pneumoniae vaccine.
Subunit vaccines include only the antigens that stimulate
the immune system, for example Dane particle from the
surface antigen of hepatitis B virus (hepatitis B vaccine).
Arunakumari et al.
Killed vaccine
Live attenuated
vaccine
Dead
pathogen
Attenuated
pathogen
Inactivation
Attenuation
Pathogen
Cloning
Fractionation
DNA vaccine
Subunit vaccine
Killed vaccines
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Vaccination in pregnancy
BCG vaccine
Measles vaccine
Mumps vaccine
Rubella vaccine
Varicella vaccine
Vaccinia vaccine
Human papillomavirus vaccine
Hepatitis A vaccine
Hepatitis B vaccine
Meningococcus vaccine
Pneumococcal vaccine
Rabies vaccine
Typhoid vaccine
Yellow fever vaccine
260
Rubella
Where the woman is known to be rubella-susceptible, the
vaccine should be given in the postpartum period.11 A single
dose of the MMR vaccine will suffice. Vaccinated women are
then advised to avoid conception for 28 days after
administration. The vaccine can also be given safely to
postpartum women who are breastfeeding. Although the
rubella virus is excreted in breast milk, only seroconversion
without serious infection has been reported in breastfeeding
infants.11 The children of pregnant women can be vaccinated
without risk to the mother or the fetus since the infection is
not transmitted from recently immunised individuals.
Varicella
Pregnant women should not be vaccinated against Varicella
zoster (chicken pox) because of the known adverse effects of
the varicella virus on the fetus.7,13 Where nonpregnant
women are vaccinated they should be advised to avoid
becoming pregnant for 4 weeks after completing the two dose
vaccine schedule.
Human papillomavirus
Human papillomavirus type 6, 11, 16, 18 virus-like particles
are not recommended for use during pregnancy as their
safety has not been evaluated in pregnant women.14,15 If a
woman is found to be pregnant after initiating the
vaccination series, the remainder of the three dose regimen
should be delayed until completion of the pregnancy.10
Influenza
Influenza is associated with greater morbidity in pregnant
women. Women in the second and third trimester of
pregnancy are at increased risk of hospitalisation from
influenza. Vaccination reduces the risk of serious maternal
medical complications and provides passive protection to the
neonate.16 It is recommended that all pregnant women have
the influenza vaccine whatever stage of pregnancy they are
at.17 However, do not administer the live attenuated
influenza virus vaccine to pregnant women.18
Arunakumari et al.
Hepatitis A
Formalin inactivated Hepatitis A is recommended if another
high risk condition or indication is present.22 High-risk
factors for Hepatitis A23 include:
Hepatitis B
Hepatitis B infection in pregnancy may result in severe
hepatic disease for the mother and chronic infection for the
baby. Hence, if a pregnant woman is in a high-risk category,
Hepatitis B vaccination should not be withheld.25 As this is
an inactivated subunit vaccine, the risks to the unborn baby
are negligible.26
Women considered to be at risk of Hepatitis B27 and
would therefore benefit from vaccination28 are:
women who inject drugs or have a partner who
injects drugs
women with multiple sexual partners
women who are close family and sexual partners of a
patient with Hepatitis B
women who receive regular blood transfusions or
blood products
women with liver disease or chronic kidney disease
women travelling to high risk countries
female sex workers
Meningococcal vaccine
There is no evidence that either vaccine, the conjugated
the quadrivalent vaccine, is unsafe.29 The usual advice is
avoid vaccination unless the mother is at high risk
disease.30 Women considered to be at high risk
meningococcal disease are those:
or
to
of
of
Typhoid
Pregnant women should be advised to avoid travel to typhoid
endemic areas but may be immunised with the inactive
parenteral vaccine if such exposure is unavoidable.33
Rabies
Rabies is virtually always fatal. Given the potentially
disastrous consequences of inadequately managed rabies
exposure to both mother and baby and the fact that it is an
inactivated viral vaccine, pregnancy is not considered a
contraindication to postexposure prophylaxis.34,35 Preexposure prophylaxis against rabies may be justified during
pregnancy, where the risk of exposure to rabies is substantial.
Yellow fever
Yellow fever is associated with a high case fatality rate. If
travel is unavoidable and the risk of yellow fever is high,
immunisation with live attenuated viral vaccine may be
considered after discussion with an infectious disease
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Vaccination in pregnancy
Conclusion
Breastfeeding and vaccination
Viral vaccines (both inactivated and live) administered to a
lactating woman do not affect the safety of breastfeeding
for women or their infants. Although there is a risk of
replication of the vaccine strain with live viral vaccines, the
majority of live viruses in vaccines have not been
demonstrated in human breast milk. Rubella vaccine
virus has been isolated in human milk, although the
virus does not usually affect the infant. Even if infection
does occur, it is well tolerated because the virus
is attenuated.
For mothers who are breastfeeding their infants,
inactivated,
recombinant,
subunit,
polysaccharide,
conjugated vaccines and toxoids pose no risk.
Breastfeeding women should be advised to avoid yellow
fever vaccine. However, where the risk of acquisition of
yellow fever is high, as in nursing mothers who cannot avoid
or postpone travel to areas endemic for yellow fever,
vaccination should not be withheld.
Thus, breastfeeding is not considered either a precaution
or a contraindication for most of the commonly used
vaccines. Furthermore, breastfeeding does not adversely
affect the success or the safety of the vaccination.37
Postpartum advice
The two vaccines that should be specifically administered
before discharge to protect the mother and the neonate are:13,38
MMR vaccine women should be counselled to avoid
becoming pregnant for 28 days after vaccination.
Varicella vaccine Varicella vaccination prepregnancy or
postpartum is an option that should be considered for
women who are found to be seronegative for VZV IgG. It
is a live attenuated vaccine administered in two separate
doses 48 weeks apart. If a woman of reproductive age is
vaccinated, she should be advised to avoid pregnancy for 1
month after each dose and to avoid contact with other
susceptible pregnant women should a postvaccination
rash occur.
Ethical issues
Although the fetus has no claim to legal rights, use of the
mother as a medium to protect her fetus has been generally
accepted by society.
Compulsory vaccination of healthcare professionals may
be an ethically justified approach where the autonomy of the
262
Disclosure of interests:
The authors have no conflicts of interest to declare.
Contribution of authorship:
PSA is the main author responsible for conception and
design, drafting the article and final approval. SK and AS
revised the article and are responsible for the final version.
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