vaccinations in pregnancy by dr shashwat jani

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.


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.


Adult immunization rates have fallen short of national goals,

partly because of misconceptions about the

safety and benefits of current vaccines.


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.


The administration of vaccines during pregnancy

poses a number of concerns about the risk of

transmitting a virus to a developing fetus.


The risk of transmitting a virus to a developing

fetus is Primarily

Theoretical…!!!


Theoretic risks of vaccination must be weighed against the

risks of the disease to mother and fetus.


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.


Vaccines that are contraindicated Live virus vaccine include:,

1.Measles, Mumps, and Rubella ( MMR )2.Varicella 3.(BCG) Bacille Calmette-Guérin4.Yellow vaccine5.Polio.


((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.


Measles, Mumps, Rubella.


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


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


Measles Mortality occurs in 1-2 per 1,000 cases often secondary to

pneumonia or encephalitis.


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.


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


Rubella( Toga virus )

Crosses the placenta barrier and cause congenital rubella syndrome.

It can cause 20% spontaneous abortion in the 1st trimester.


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.


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.


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.


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).


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.


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.


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.


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.


YELLOW FEVER

It is indicated for use in laboratory workers

involved with the virus and in persons planning to

travel to endemic areas.


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.


YELLOW FEVER

When travel cannot be postponed and mosquito

exposure is likely,

Yellow fever vaccination

may be considered.


Inactivated vaccines:

Inactivated Viral Vac. Inactivated bacteria Vac.

- Influenza -Cholera

- Rabies -Typhoid

- Hepatitis B -pneumococcus


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.


Influenza

The influenza vaccine is a killed virus preparation

with an annually adjusted antigenic

makeup.


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.


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.


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


Hepatitis B

Transmitted through: 1.Contact with infected blood, 2.Sexual activity, and 3.Sharing of intravenous needles.


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.


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.


TYPHOID

Transmission of Salmonella typhi is significantly increased with travel during epidemics and ingestion of food from street vendors.


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.


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.


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.


Pneumococcal

Risk factors for pneumococcal infection in pregnant women

include 1. Diabetes, 2. Cardiovascular disease, 3. Immunodeficiency, 4. Asthma.


Pneumococcal

The current vaccine includes purified capsular polysaccharide.

women at high risk should be given this vaccination before,

but not during, pregnancy.


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.


ImG vaccines

Specific Immune globulins vaccine:Hepatitis BRabiesTetanusVaricella


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.


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.


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.


Tetanus and Diphtheria


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.


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.


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


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.


Other Vaccinations . . .


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.)


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


Meningococcal

Studies have shown that the meningococcal vaccine is safe and efficacious when given to pregnant women


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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