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VACCINATIONS IN PREGNANCY
Dr SHASHWAT JANI M.S. ( OBS - GYN ).
Diploma in Advanced Endoscopy.Assistant Professor, Sheth V. S. General hospital.
Smt. N.H.L. Municipal Medical College, Ahmedabad.
Mobile : +91 99099 44160.E- mail : [email protected]
Dr. Shashwat K. Jani. 99099 44160 1
OBJECTIVE To induce a state
of immunity in the patient so that confrontation with offending organism can be successful in protecting the host.
Dr. Shashwat K. Jani. 99099 44160 2
The vaccines are prepared from inactivated, live attenuated , modified or mutant forms of the causative agents.
Live vaccines induce prompt but transient production of Abs. while Inactivated vaccines and Toxoids produce a less complete response and several doses are required.
Dr. Shashwat K. Jani. 99099 44160 3
Adult immunization rates have fallen short of national goals,
partly because of misconceptions about the
safety and benefits of current vaccines.
Dr. Shashwat K. Jani. 99099 44160 4
The danger of these misconceptions is magnified during pregnancy, when:
1.Concerned physicians are hesitant to administer vaccines.
2.Patients are reluctant to accept them.
Dr. Shashwat K. Jani. 99099 44160 5
The administration of vaccines during pregnancy
poses a number of concerns about the risk of
transmitting a virus to a developing fetus.
Dr. Shashwat K. Jani. 99099 44160 6
The risk of transmitting a virus to a developing
fetus is Primarily
Theoretical…!!!
Dr. Shashwat K. Jani. 99099 44160 7
Theoretic risks of vaccination must be weighed against the
risks of the disease to mother and fetus.
Dr. Shashwat K. Jani. 99099 44160 8
Physicians should reassure their patients that
NO vaccines are contraindicated
during breastfeeding.Dr. Shashwat K. Jani. 99099 44160 9
Immunization during Immunization during breastfeeding is safebreastfeeding is safe
Routine vaccines that generally are Safe during pregnancy include:
1.Diphtheria 5.Meningococcal2.Tetanus 6. Rabies.3.Influenza
4.Hepatitis B.
Dr. Shashwat K. Jani. 99099 44160 10
Vaccines that are contraindicated Live virus vaccine include:,
1.Measles, Mumps, and Rubella ( MMR )2.Varicella 3.(BCG) Bacille Calmette-Guérin4.Yellow vaccine5.Polio.
Dr. Shashwat K. Jani. 99099 44160 11
((Because of the theoretic Because of the theoretic risk of fetal transmissionrisk of fetal transmission))
If a live-virus vaccine is inadvertently given to a pregnant woman, or if a woman becomes pregnant within four weeks after
vaccination, she should be counseled about potential effects
on the fetus.
Dr. Shashwat K. Jani. 99099 44160 12
Measles, Mumps, Rubella.
Dr. Shashwat K. Jani. 99099 44160 13
Measles ( Rubi virus)
Typically presents with: 1.Fever, red eyes2.Coryza )inflammation of mucosal mem. Lining the nasal cavity(3.Generally ill appearance, and 4.maculopapular rash start at face to chest
Dr. Shashwat K. Jani. 99099 44160 14
Measles Risk from disease to pregnant woman:
Causes significant morbidity and low mortality
Risk from disease to fetus or neonate:Sign. Increase in abortion rateMay cause fetal malformation
Dr. Shashwat K. Jani. 99099 44160 15
Measles Mortality occurs in 1-2 per 1,000 cases often secondary to
pneumonia or encephalitis.
Dr. Shashwat K. Jani. 99099 44160 16
Mumps
Mumps results from infection with the paramyxovirus and can lead to parotitis, meningoencephalitis, and orchitis.
Neurologic complications such as deafness, can also occur as a result of mumps infection.
Dr. Shashwat K. Jani. 99099 44160 17
Mumps
- Contraindicated because it’s a live attenuated vaccine, carrying a risk of causing the mump infection
- Can cause early miscarriage or birth defects
- Most common birth defect is - deafness
Dr. Shashwat K. Jani. 99099 44160 18
Rubella( Toga virus )
Crosses the placenta barrier and cause congenital rubella syndrome.
It can cause 20% spontaneous abortion in the 1st trimester.
Dr. Shashwat K. Jani. 99099 44160 19
Congenital Rubella syndromeCan result in defects such as:* Malformations of the heart )especially PDA(, eyes
or brain * Deafness* Spleen, liver or bone marrow problems )some of
which may disappear shortly after birth( * Mental retardation * Small head size )microcephaly( * Eye defects - cataracts* Low birth weight * Hepatomegaly.
Dr. Shashwat K. Jani. 99099 44160 20
Measles, mumps, and rubella vaccine should not be given to pregnant women, because
of potential adverse effects on the fetus.
But
should be vaccinated post partum.
Dr. Shashwat K. Jani. 99099 44160 21
Polio RNA Enterovirus with three different strains
that cause disease. Exposure may result in asymptomatic
infection as well as non paralytic and paralytic disease.
Asymptomatic patients can transmit the disease to susceptible persons.
Dr. Shashwat K. Jani. 99099 44160 22
Polio
The disease continues to be a problem worldwide, but all recent domestic polio cases have been caused by the strains of virus found in the oral polio vaccine (OPV).
Dr. Shashwat K. Jani. 99099 44160 23
Polio This situation has resulted in a
change in the recommendation for use of inactivated polio vaccine )IPV(, instead of OPV or a combination of OPV-IPV for all routine vaccinations.
IPV is inactivated by formaldehyde, and its use has eliminated vaccine-associated polio infection.
Dr. Shashwat K. Jani. 99099 44160 24
Polio
Although no adverse effects have been documented with
OPV or IPV in pregnant women or their fetuses, both vaccines should be avoided
during pregnancy on a theoretic basis.
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Polio
The CDC states that IPV may be administered in
accordance with the recommended schedules for adults if a pregnant woman is at increased risk for infection
and requires immediate protection against polio.
Dr. Shashwat K. Jani. 99099 44160 26
YELLOW FEVER Yellow fever is a viral hemorrhagic
fever syndrome spread by mosquitoes in parts of South America and Africa.
The yellow fever vaccine is a live, attenuated virus grown in chick embryos.
Dr. Shashwat K. Jani. 99099 44160 27
YELLOW FEVER
It is indicated for use in laboratory workers
involved with the virus and in persons planning to
travel to endemic areas.
Dr. Shashwat K. Jani. 99099 44160 28
YELLOW FEVER
No specific evidence is available to demonstrate the safety of yellow fever immunization during pregnancy.
Since theoretic concerns of fetal infection exist, however, vaccination is generally not recommended during pregnancy.
Dr. Shashwat K. Jani. 99099 44160 29
YELLOW FEVER
When travel cannot be postponed and mosquito
exposure is likely,
Yellow fever vaccination
may be considered.
Dr. Shashwat K. Jani. 99099 44160 30
Inactivated vaccines:
Inactivated Viral Vac. Inactivated bacteria Vac.
- Influenza -Cholera
- Rabies -Typhoid
- Hepatitis B -pneumococcus
Dr. Shashwat K. Jani. 99099 44160 31
Influenza Fever, malaise, myalgia, and
upper respiratory tract symptoms or infections characterize influenza infection.
Most severe complications are the result of pneumonia secondary to influenza infection.
Dr. Shashwat K. Jani. 99099 44160 32
Influenza
The influenza vaccine is a killed virus preparation
with an annually adjusted antigenic
makeup.
Dr. Shashwat K. Jani. 99099 44160 33
Influenza
It should be administered annually between October and December to high-risk
patients. Dr. Shashwat K. Jani. 99099 44160 34
Influenza
The vaccine should be administered to all pregnant
women who will be in the second or third trimester of
pregnancy during the
influenza season.Dr. Shashwat K. Jani. 99099 44160 35
Influenza Women in their second or third trimesters
have higher morbidity, from influenza infection.
Immunization should be avoided in most patients during the first trimester to avoid a coincidental association with spontaneous abortion, which is common in the first trimester.
Dr. Shashwat K. Jani. 99099 44160
36
RABIES Rabies is a viral infection transmitted most
commonly by the saliva of infected animals. Nonspecific prodromal symptoms progress
to encephalitis marked by confusion,
hallucinations.
Dr. Shashwat K. Jani. 99099 44160
37
RABIES Dysregulation of the autonomic nervous
system and involvement of the brainstem and cranial nerves lead to the classic "foaming at the mouth" appearance.
Three forms of inactivated rabies vaccines are available, all considered equally safe and efficacious.
Dr. Shashwat K. Jani. 99099 44160 38
RABIES
Passive immunization is achieved through administration of human rabies immune globulin )HRIG(.
It may be considered in animal workers and travelers to enzootic areas who anticipate animal exposure.
Dr. Shashwat K. Jani. 99099 44160 39
RABIES In patients who have not been immunized
previously, 20 IU per kg of HRIG is given at the wound site for high-risk bites or if testing is positive.
Patients with previous vaccinations do not need HRIG but do require revaccination on a modified schedule.
There have been no identified associations between rabies vaccination and fetal abnormalities
Dr. Shashwat K. Jani. 99099 44160 40
Hepatitis B
Transmitted through: 1.Contact with infected blood, 2.Sexual activity, and 3.Sharing of intravenous needles.
Dr. Shashwat K. Jani. 99099 44160 41
Hepatitis B
Risk factors for a pregnant woman include:
1. Having multiple sexual partners,
2. Using or abusing intravenous drugs,
3. Having occupational exposure, and
4. Being a household contact of acutely infected persons or persons with a chronic carrier state.
Dr. Shashwat K. Jani. 99099 44160 42
Hepatitis B
Because it contains noninfectious hepatitis B surface antigen particles and it cause
no risk to the fetus, neither pregnancy nor lactation is a contraindication to vaccination.
Dr. Shashwat K. Jani. 99099 44160 43
TYPHOID
Transmission of Salmonella typhi is significantly increased with travel during epidemics and ingestion of food from street vendors.
Dr. Shashwat K. Jani. 99099 44160 44
TYPHOID The two types of typhoid vaccination in use
today are a live attenuated oral vaccine and a parenteral polysaccharide vaccine.
Both forms require that immunization be completed at least two weeks before exposure.
Dr. Shashwat K. Jani. 99099 44160 45
TYPHOID Neither form of typhoid vaccine is
officially recommended during
pregnancy. Dr. Shashwat K. Jani. 99099 44160 46
CHOLERA Two improved oral vaccines are available :
1. a killed, whole cell recombinant vaccine and
2. a live, attenuated strain. Both are more effective, better tolerated, and
longer lasting than the parenteral vaccine.
Dr. Shashwat K. Jani. 99099 44160 47
These may be considered for use in These may be considered for use in populations at immediate risk of a populations at immediate risk of a cholera epidemic or for travelers to cholera epidemic or for travelers to
areas of high endemicity.areas of high endemicity.
CHOLERA No specific information exists on the
safety of parenteral cholera vaccination during pregnancy.
Because cholera during pregnancy is a serious illness, exposure should be minimized during pregnancy whenever possible.
Dr. Shashwat K. Jani. 99099 44160 48
Pneumococcal
Risk factors for pneumococcal infection in pregnant women
include 1. Diabetes, 2. Cardiovascular disease, 3. Immunodeficiency, 4. Asthma.
Dr. Shashwat K. Jani. 99099 44160 49
Pneumococcal
The current vaccine includes purified capsular polysaccharide.
women at high risk should be given this vaccination before,
but not during, pregnancy.
Dr. Shashwat K. Jani. 99099 44160 50
Pneumococcal The safety of the vaccine
during pregnancy has not been evaluated, although no adverse outcomes have been
reported among newborns whose mothers were
inadvertently vaccinated.
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ImG vaccines
Specific Immune globulins vaccine:Hepatitis BRabiesTetanusVaricella
Dr. Shashwat K. Jani. 99099 44160 52
Varicella ( Chicken Pox )
Varicella vaccination is a live attenuated virus and is contraindicated during pregnancy.
Women who are vaccinated should avoid becoming pregnant for one month following each injection.
The presence of pregnant household members does not constitute a contraindication to vaccination of others within the house.
Dr. Shashwat K. Jani. 99099 44160 53
Adverse effects:- Characterized by limb
atrophy and scarring of the skin of the extremity, known as congenital varicella syndrome.
- Other manifestations include central nervous system and eye abnormalities.
- Increase mortality in neonates.
Dr. Shashwat K. Jani. 99099 44160 54
Varicella immunoglobulin indicated: If a susceptible pregnant woman is exposed to
varicella, however, administration of varicella-zoster immune globulin should be strongly considered
Indicated also for newborns of mothers who developed varicella within 4 days prior to delivery or 2 days following delivery.
Approx. 90-95% of adults are immune
Not indicated for prevention of congenital varicella.
Dr. Shashwat K. Jani. 99099 44160 55
Tetanus and Diphtheria
Dr. Shashwat K. Jani. 99099 44160 56
Diphtheria is an infection of the nasal, pharyngeal, laryngeal, or other mucous membranes that can cause neuritis, myocarditis, thrombocytopenia, and ascending paralysis.
Tetanus infection can cause production of a neurotoxin, leading to tetanic muscle contractions.
Dr. Shashwat K. Jani. 99099 44160 57
While no evidence exists to prove that tetanus and diphtheria toxoids are teratogenic, waiting until the second trimester of pregnancy to administer toxoids is a reasonable precaution, minimizing any concern about the theoretic possibility of such reactions.
Dr. Shashwat K. Jani. 99099 44160 58
Who needs the Tetanus and Diphtheria vaccine?
According to CDC guidelines :
1ST dose between 16 -20 weeks &
2nd dose after 4 – 6 weeks .
Previously vaccinated pregnant women who have not received a Td vaccination within the past 10 years should receive a booster dose.
O.5 ml Intramuscular in upper arm
Dr. Shashwat K. Jani. 99099 44160 59
Tetanus and Diphtheria
In INDIA :
Where tetanus infection is common in neonates and Antenatal visits are not regular in rural areas…
Govt. Of India Guidelines :
1st dose at 1st ANC visit &
2nd after 4-6 weeks.
Dr. Shashwat K. Jani. 99099 44160 60
Other Vaccinations . . .
Dr. Shashwat K. Jani. 99099 44160 61
HPV VACCINE Not recommended for use in pregnancy. If patient becomes pregnant - Delay remaining
doses till delivery. If vaccinated during pregnancy - No intervention
)MTP( needed. Lactating women can receive the HPV vaccine
)Gardasil( and still continue breastfeeding as it is a vaccine without live viral DNA.
( FOGSI Recommendations: Pregnancy & Lactation.)
Dr. Shashwat K. Jani. 99099 44160 62
Hepatitis A
Administration of immune globulin is strongly recommended which is considered safe during pregnancy and is more than 85 % effective in preventing acute hepatitis
Dr. Shashwat K. Jani. 99099 44160 63
Meningococcal
Studies have shown that the meningococcal vaccine is safe and efficacious when given to pregnant women
Dr. Shashwat K. Jani. 99099 44160 64
BCG VACCINE BCG )Bacille Calmette-Guérin( vaccine is a live
vaccine derived from a strain of Mycobacterium bovis.
Use of the BCG vaccine is NOT recommended during pregnancy.
Pre conceptional immunization of pregnant women to prevent disease in the offspring is preferred to vaccination of pregnant women.
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Dr. Shashwat K. Jani. 99099 44160 66
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