Vaccinations in pregnancy


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Vaccinations in pregnancy

  1. 1. Vaccinations in Pregnancy Doris K Ramirez MD UAG Obstetrics
  2. 2. Adult immunization rates have fallen short of national goals, partly because of misconceptions about the safety and benefits of current vaccines.
  3. 3. • The danger of these misconceptions is magnified during pregnancy, when: 1.Concerned physicians are hesitant to administer vaccines and 2.Patients are reluctant to accept them.
  4. 4. •The administration of vaccines during pregnancy poses a number of concerns about the risk of transmitting a virus to a developing fetus.
  5. 5. The risk of transmitting a virus to a developing fetus is primarily theoretical
  6. 6. •Theoretic risks of vaccination must be weighed against the risks of the disease to mother and fetus.
  7. 7. Physicians should reassure their patients that no vaccines are contraindicated during breastfeeding. Immunization duringImmunization during breastfeeding is safebreastfeeding is safe
  8. 8. Routine vaccines that generally are safe during pregnancy include: 1.Diphtheria 5.Meningococcal 2.Tetanus 6. rabies 3.Influenza 4.Hepatitis B.
  9. 9. Vaccines that are contraindicated live virus vaccine include:, 1. Measles, Mumps, and Rubella; 2. Varicella 3. (BCG) bacille Calmette-Guérin 4. Yellow vaccine 5. Polio ))because of the theoretic risk ofbecause of the theoretic risk of fetal transmissionfetal transmission((
  10. 10. 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.
  11. 11. Measles, Mumps, and Rubella
  12. 12. Measles “Rubeola” Rubeola is a member of the rubivirus.
  13. 13. • typically presents with: 1. Fever, red eyes 2. Coryza (inflammation of mucosal mem. Lining the nasal cavity) 3. Generally ill appearance, and 4. maculopapular rash start @face to chest Measles “Rubeola”
  14. 14. Measles • Risk from disease to pregnant woman: – Causes significant morbidity and low mortality – There is no evidence that measles (rubeola) can cause malformations of the developing embryo and fetus. • Risk from disease to fetus or neonate: – Sign. Increase in abortion rate – May cause fetal malformation
  15. 15. •Mortality occurs in 1-2 per 1,000 cases, often secondary to pneumonia or encephalitis. Measles
  16. 16. Rubeola There is no evidence whatsoever that measles (rubeola) can cause malformations of the developing embryo and fetus. Measles can, however, trigger miscarriages (spontaneous abortions) and premature delivery in pregnant women
  17. 17. • 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
  18. 18. 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
  19. 19. Rubella “German Measles: •Rubella is caused by the togavirus.
  20. 20. Rubella Crosses the placenta barrier and cause congenital rubella syndrome. It can cause 20% spontaneous abortion in the 1st trimester.
  21. 21. Congenital Rubella syndrome Can 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
  22. 22. •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.
  23. 23. Polio
  24. 24. • RNA Enterovirus with three different strains that cause disease. • Exposure may result in asymptomatic infection as well as nonparalytic and paralytic disease. • Asymptomatic patients can transmit the disease to susceptible persons. Polio
  25. 25. • 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
  26. 26. • 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
  27. 27. • 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
  28. 28. • 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. Polio
  29. 29. YELLOW FEVER
  30. 30. • 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
  31. 31. •It is indicated for use in laboratory workers involved with the virus and in persons planning to travel to endemic areas. YELLOW FEVER
  32. 32. • 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
  33. 33. •When travel cannot be postponed and mosquito exposure is likely, yellow fever vaccination may be considered. YELLOW FEVER
  34. 34. Inactivated vaccines: Inactivated Viral Vac. Inactivated bacteria Vac: - Influenza -Cholera - Rabies -Typhoid - Hepatitis B -pneumococcus
  35. 35. Influenza
  36. 36. • 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
  37. 37. •The influenza vaccine is a killed virus preparation with an annually adjusted antigenic makeup. Influenza
  38. 38. •It should be administered annually between October and December to high-risk patients. Influenza
  39. 39. •The vaccine should be administered to all pregnant women who will be in the second or third trimester of pregnancy during the influenza season Influenza
  40. 40. • 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. Influenza
  41. 41. RABIES
  42. 42. • Rabies is a viral infection transmitted most commonly by the saliva of infected animals. • Nonspecific prodromal symptoms progress to encephalitis marked by confusion, hallucinations. RABIES
  43. 43. • 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
  44. 44. • Passive immunization is achieved through administration of human rabies immune globulin (HRIG). • Indications for pre-exposure immunization depend on the likelihood of exposure. • It may be considered in animal workers and travelers to enzootic areas who anticipate animal exposure. RABIES
  45. 45. •With any animal bites or wild animals, the animal should be euthanized, and the brain tested for infection. RABIES
  46. 46. •Bites from normally acting dogs, cats warrant a 10-day observation period, with prophylaxis and euthanization of the animal deferred. RABIES
  47. 47. • 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 RABIES
  48. 48. Hepatitis B
  49. 49. •How is hepatitis B transmitted?
  50. 50. • Transmitted through: 1.Contact with infected blood, 2.Sexual activity, and 3.Sharing of intravenous needles. Hepatitis B
  51. 51. • The risk of developing chronic illness associated with complications (cirrhosis, hepatocellular carcinoma, and a chronic carrier state) has been a key factor in the recommendation for universal vaccination of all children Hepatitis B
  52. 52. 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
  53. 53. • The hepatitis B vaccine contains viral surface antigen produced by recombinant DNA technology. • It is administered in the fetus at three doses, at birth and at one and six months of age, and has minimal to no side effects. Hepatitis B
  54. 54. • 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. Hepatitis B
  55. 55. TYPHOID
  56. 56. • Most cases of typhoid fever in developed countries occur in travelers who recently have returned from high-risk areas, such as South America, India, and western Africa TYPHOID
  57. 57. • Transmission of Salmonella typhi is significantly increased with travel during local epidemics and ingestion of food from street vendors. TYPHOID
  58. 58. Primary prevention consists of: 1. Hand washing, 2. Drinking only safe water, 3. Peeling all fruits and vegetables, and 4. Eating well-cooked foods. TYPHOID
  59. 59. • 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
  60. 60. • Its use is contraindicated in: 1. Infants, 2. Immunocompromised persons, and 3. Those with abnormal gastrointestinal function, as well as 4. Pregnant women. TYPHOID
  61. 61. •Neither form of typhoid vaccine is officially recommended during pregnancy. TYPHOID
  62. 62. CHOLERA
  63. 63. • Cholera is an acute diarrheal disease endemic to Africa, Asia, and Latin America. • It is caused by a toxin from Vibrio cholera bacteria, which live in, and are transmitted by, the fecal-oral route from contaminated water sources. CHOLERA
  64. 64. • 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. CHOLERA These may be considered for use inThese may be considered for use in populations at immediate risk of a cholerapopulations at immediate risk of a cholera epidemic or for travelers to areas of highepidemic or for travelers to areas of high endemicity.endemicity.
  65. 65. • 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. CHOLERA
  66. 66. Pneumococcal
  67. 67. • Streptococcus pneumoniae is a gram-positive diplococci that is a major cause of 1.Pneumonia, 2.Meningitis, and 3.Bacteremia. Pneumococcal
  68. 68. • Risk factors for pneumococcal infection in pregnant women include 1. Diabetes, 2. Cardiovascular disease, 3. Immunodeficiency, 4. Asthma. Pneumococcal
  69. 69. • The current vaccine includes purified capsular polysaccharide • women at high risk should be given this vaccination before, but not during, pregnancy. Pneumococcal
  70. 70. • 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. Pneumococcal
  71. 71. ImG vaccines • Specific Immune globulins vaccine: –Hepatitis B –Rabies –Tetanus –Varicella
  72. 72. Varicella
  73. 73. Varicella vaccination is a live attenuated virus and is contraindicated during pregnancy.
  74. 74. 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.
  75. 75. • The varicella-zoster virus causes chickenpox and rarely cause serious complications, (as encephalitis and severe pneumonia). • Up to 15 % of infected persons have herpes zoster later in life. Varicella
  76. 76. • 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. Varicella
  77. 77. 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
  78. 78. Tetanus and Diphtheria
  79. 79. •Diphtheria is an infection of the nasal, pharyngeal, laryngeal, or other mucous membranes that can cause neuritis, myocarditis, thrombocytopenia, and ascending paralysis.
  80. 80. •Tetanus infection can cause production of a neurotoxin, leading to tetanic muscle contractions.
  81. 81. Tetanus toxoid is routinely recommended for susceptible pregnant women.
  82. 82. • 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.
  83. 83. •Previously vaccinated pregnant women who have not received a Td vaccination within the past 10 years should receive a booster dose. Who needs the Tetanus and Diphtheria vaccine?
  84. 84. •Pregnant women who are not immunized or only partially immunized should complete the primary series. Tetanus and Diphtheria
  85. 85. Other Vaccinations
  86. 86. Hepatitis A
  87. 87. •How is Hepatitis A acquired?
  88. 88. •It is acquired via the fecal- oral route by person- to-person contact or ingestion of contaminated food or water. Hepatitis A
  89. 89. • Safety during pregnancy has not been determined. • Because hepatitis A vaccine is produced from inactivated virus, the risk to the developing fetus is expected to be low. Hepatitis A
  90. 90. • Administration of immune globulin is strongly recommended; which is considered safe during pregnancy and is more than 85 % effective in preventing acute hepatitis Hepatitis A
  91. 91. Meningococcal
  92. 92. • In the USA, meningococcal disease is the leading cause of bacterial meningitis in children ages two through 18 years. • Meningococcal vaccine contains the purified polysaccharide of four serogroups of Neisseria meningitidis. Meningococcal
  93. 93. • Routine vaccination is recommended for high-risk groups, including 1. Military recruits, 2. Patients with terminal complement component deficiencies 3. Persons with anatomic or functional asplenia. 4. High school or college students Meningococcal
  94. 94. • Vaccination also may benefit travelers to areas in which N. meningitidis is endemic or epidemic, such as Africa. • Studies have shown that the meningococcal vaccine is safe and efficacious when given to pregnant women Meningococcal
  95. 95. • Vaccinations typically not administered on a routine basis by family physicians and other vaccines of interest include: anthrax, smallpox, rabies, yellow fever, BCG, typhoid, and cholera.
  96. 96. ANTHRAX
  97. 97. • Anthrax is caused by the spore- forming bacterium Bacillus anthracis, occurring in humans in three forms: 1. Cutaneous, 2. Inhalational, and 3. Gastrointestinal. ANTHRAX
  98. 98. • The potential use of anthrax in acts of bioterrorism has long been a concern because of its: 1. Stability, 2. High mortality, and 3. High potential for respiratory transmission. ANTHRAX
  99. 99. •The anthrax vaccine is prepared from a bacteria-free culture containing the three major toxin components produced by the bacteria ANTHRAX
  100. 100. The recommended immunization schedule consists of: 1. Three injections given at two- week intervals, followed by another 2. Three doses at six-month intervals. ANTHRAX
  101. 101. • No studies have addressed the safety of the anthrax vaccine during pregnancy. • As with other non -live- virus vaccines, anthrax vaccine does not carry theoretic risks of fetal infection. ANTHRAX
  102. 102. • Vaccination should be considered on a case-by-case basis and administered only when the potential benefits outweigh the potential risks to the mother and fetus. ANTHRAX
  103. 103. SMALLPOX
  104. 104. •Smallpox is an orthopoxvirus, was certified as eradicated in 1980, and no longer occurs naturally. SMALLPOX
  105. 105. • Prodromal symptoms include a high fever and oral lesions that ulcerate, followed by a macular rash. • The rash becomes raised, then umbilicated and pustular, particularly when on the face and extremities. SMALLPOX
  106. 106. • Recent world events have brought to light the threat of terrorists who may release smallpox, and have prompted an evaluation of vaccination policies SMALLPOX
  107. 107. •Vaccinia vaccine should not be administered to pregnant women for routine nonemergency indications. SMALLPOX
  108. 108. •Smallpox infection among pregnant women has been reported to result in a more severe infection than among nonpregnant women. SMALLPOX
  109. 109. • The vaccine has not been shown to be teratogenic or to cause congenital malformations, but the virus has been reported to cause fetal infection on rare occasion, with subsequent risk of skin lesions, preterm delivery, stillbirth, or infant death. SMALLPOX
  110. 110. • Women should therefore actively avoid becoming pregnant for at least four weeks after vaccination and until the scab has completely healed and fallen off. SMALLPOX
  111. 111. • Vaccination should also be avoided for household or close contacts of women who are pregnant. • Inadvertent vaccination during pregnancy, however, should not be considered a reason to terminate the pregnancy SMALLPOX
  112. 112. • The safety of breast milk after maternal vaccination has not been studied, so women who are breastfeeding should not receive the vaccine. • Household contacts of breastfeeding infants theoretically can be immunized. SMALLPOX
  113. 113. BCG VACCINE
  114. 114. •Mycobacterium tuberculosis causes more than 8 million new cases of tuberculosis (TB) annually, the majority of them in developing countries. BCG VACCINE
  115. 115. •BCG (bacille Calmette-Guérin) vaccine is a live vaccine derived from a strain of Mycobacterium bovis. BCG VACCINE
  116. 116. • It is likely that the BCG vaccine has been given to thousands of pregnant women in other countries. • While no harmful fetal side effects have been identified to date. BCG VACCINE
  117. 117. •Use of the BCG vaccine is not recommended during pregnancy. BCG VACCINE
  118. 118. •Preconceptional immunization of pregnant women to prevent disease in the offspring is preferred to vaccination of pregnant women.
  119. 119. •The benefits of immunization to the pregnant woman and her neonate usually outweigh the theoretic risks of adverse effects.
  120. 120. •The theoretic risks of the vaccination of pregnant women with killed virus vaccines have not been identified.
  121. 121. •Vaccination of women during the postpartum period, especially for rubella and varicella, should be encouraged.
  122. 122. •Women susceptible to rubella should be vaccinated with measles– mumps–rubella on postpartum discharge from the hospital.
  123. 123. •Generally, live-virus vaccines are contraindicated for pregnant women because of the theoretical risk of transmission of the vaccine virus to the fetus.
  124. 124. • Whether live or inactivated vaccines are used, vaccination of pregnant women should be considered on the basis of the risk of the vaccination vs. the benefits of protection in a particular circumstance.