Maternal immunization

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

Immunization prevents illness, disability and death from vaccine-preventable diseases. Vaccines are useful to reduce childhood mortality and morbidity. Vaccination schedule starts at early infancy and it's not complete by age of 6 months. Therefore, most of the children do not have coverage during the early infancy with adequate protection which may predispose them to infections. This gap may result in higher infection related hospitalization and disease complications in early infancy than in older children. Maternal vaccination has became to consideration to cover this gap. However it can protect mother from acquiring infection it is also effective for infant protection.

Immunology

Maternal immunity changes during the pregnancy under influence of hormonal changes. Increased level of estrogen and progesterone are the most important factors for these changes. Increased level of estradiol is associated with increased level of T-helper type 2 cell response compared to type 1 T-cells.[1][2] However, increased level of progesterone may result in decrease in immune response and alteration in immune system.[3][4] Other aspect of immune response such as, phagocytosis and number of neutrophils and monocytes remains unchanged.[4]
These changes (alteration in cell mediated immunity) explain sub-optimal immune response to some certain viral infections such as influenza. Furthermore, it justifies the need for immunization against these infections.[5] Other parts of immune system remains intact during pregnancy and immunosuppresion does not encounter during pregnancy.
Clinical effectiveness of vaccination during pregnancy is maintained and changes in immune balance does not influence their effectiveness.[6][7][8]

Maternal immunization recommendation

Inactivated influenza and combined tetanus-diphteria-acellular pertussis (TDaP) are recommended for pregnant women in the U.S. Hepatitis B and hepatitis E vaccines are recommended in some other countries.
The following table summarize the vaccines and current recommendations for their administration during pregnancy.

Vaccine Type Recommendation for pregnant women Specific consideration
Category Comment
Anthrax Inactivated May be used in women with high risk of exposure; not recommended for

those with low risk of exposure.

Travel and other Generally, inactivated vaccines are safe in pregnancy but anthrax vaccine is reserved for high risk mothers only.
BCG Live Contraindicated Travel and other Live vaccines are contraindicated in pregnancy however, there is no report for BCG adverse effects in pregnancy
HAV Inactivated Recommended for specific indications Routine Indications:
  • History of injection or noninjection illicit drug use
  • Work with HAV-infected primates
  • Work with HAV in a research laboratory
  • Chronic liver disease
  • Receive clotting factor concentrates
  • Travel to or work in countries with high or intermediate endemicity of hepatitis A
HBV Recombinant Recommended for specific indications Routine Indications:
  • If have had a HBsAg-positive sex partner
  • Have had more than one sex partner during the previous 6 mo
  • Have been evaluated or treated for an STD
  • History of recent or current injection-drug use

The recommended schedule is 0, 1, and 6 mo.

HPV Inactivated Not recommended Routine If a woman is found to be pregnant during the administration of an HPV series, the remaining doses should be delayed until after pregnancy is completed.
Influenza Inactivated Recommended Routine Recommended for all women who are or will be pregnant during influenza season.
Live, attenuated Contraindicated Routine Risk of fetal infection
Japanese encephalitis virus Inactivated Inadequate data for specific recommendation Travel and other Theoretical risk for fetus however, it is recommended for pregnant women traveling to a high risk area.
Meningococcal Inactivated
  • Serotype ACWY conjugate vaccine may be used in the case of a specific indication
  • Serotype B vaccine administration should be based on a risk–benefit assessment for the patient
 Routine
MMR Live Contraindicated Routine Live vaccines are contraindicated during pregnancy.

If the vaccine is inadvertently given to a pregnant woman, she should be informed of the theoretical risks to the fetus.

However, receipt of the vaccine is not an indication for termination of pregnancy.

Pneumococcal Conjugate

(PCV13)

Inactivated Inadequate data for specific recommendation Routine
Polysaccharide

(PPSV23)

Inactivated Inadequate data for specific recommendation Routine It found to be safe in 2nd and 3rd trimesters. But, it seems that it's not effective to prevent infant pneumococcal infection.(19)
Poliovirus, Inactivated May be used if needed Routine Indicated for high risk women (travel to endemic area or occupational exposure)
Rabies virus Inactivated May be used if needed Travel and other

Refernces

  1. ↑ Lindheimer MD, Cunningham FG (2014). "Pregnancy and infection". N. Engl. J. Med. 371 (11): 1076–7. doi:10.1056/NEJMc1408436#SA3. PMID 25207785.
  2. ↑ Straub RH (2007). "The complex role of estrogens in inflammation". Endocr. Rev. 28 (5): 521–74. doi:10.1210/er.2007-0001. PMID 17640948.
  3. ↑ Szekeres-Bartho J, Wegmann TG (1996). "A progesterone-dependent immunomodulatory protein alters the Th1/Th2 balance". J. Reprod. Immunol. 31 (1–2): 81–95. PMID 8887124.
  4. ↑ 4.0 4.1 Robinson DP, Klein SL (2012). "Pregnancy and pregnancy-associated hormones alter immune responses and disease pathogenesis". Horm Behav. 62 (3): 263–71. doi:10.1016/j.yhbeh.2012.02.023. PMC 3376705. PMID 22406114.
  5. ↑ Pazos M, Sperling RS, Moran TM, Kraus TA (2012). "The influence of pregnancy on systemic immunity". Immunol. Res. 54 (1–3): 254–61. doi:10.1007/s12026-012-8303-9. PMID 22447351.
  6. ↑ Schlaudecker EP, McNeal MM, Dodd CN, Ranz JB, Steinhoff MC (2012). "Pregnancy modifies the antibody response to trivalent influenza immunization". J. Infect. Dis. 206 (11): 1670–3. doi:10.1093/infdis/jis592. PMID 22984116.
  7. ↑ Sperling RS, Engel SM, Wallenstein S, Kraus TA, Garrido J, Singh T, Kellerman L, Moran TM (2012). "Immunogenicity of trivalent inactivated influenza vaccination received during pregnancy or postpartum". Obstet Gynecol. 119 (3): 631–9. doi:10.1097/AOG.0b013e318244ed20. PMC 3327739. PMID 22353963.
  8. ↑ Munoz FM, Bond NH, Maccato M, Pinell P, Hammill HA, Swamy GK, Walter EB, Jackson LA, Englund JA, Edwards MS, Healy CM, Petrie CR, Ferreira J, Goll JB, Baker CJ (2014). "Safety and immunogenicity of tetanus diphtheria and acellular pertussis (Tdap) immunization during pregnancy in mothers and infants: a randomized clinical trial". JAMA. 311 (17): 1760–9. doi:10.1001/jama.2014.3633. PMC 4333147. PMID 24794369.
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