nil

1. Maternal immunisation to protect the infant:
The Present and future
Dr. Milap Sharma
Professor Pediatrics
DRPGMC KANGRA

2. VACCINES DURING PREGNANCY AS PER NIS
VACCINE When to give Dose Route site
TT-1 Early in
pregnancy
0.5 ml Intra-muscular Upper Arm
TT-2 4 weeks after
TT-1*
0.5 ml Intra-muscular Upper Arm
TT Booster TT- Booster If
received 2 TT
doses in a
pregnancy
within the last
3 yrs*
0.5 ml Intra-muscular Upper Arm

3. Growing evidence on the safety and efficacy of influenza and tetanus,
diphtheria, and pertussis (Tdap) immunizations in pregnancy has
highlighted maternal immunization as an important strategy to reduce
morbidity and mortality in women and newborns

4. Why Pregnant women and neonates are particularly vulnerable to infectious
disease
 Altered and underdeveloped immune
responses
 Provides maternal protection through
active immunization
 Passive maternal antibody transfer across
the placenta to the developing fetus has
the potential to protect neonates and
infants.
 Prior to the COVID-19 pandemic in 2020,
pertussis was on the rise
Some of the Vaccines are not effective at birth-
window period
Some vaccines i.e. RSV, influenza and
pertussis do not provide long term
immunity
Recommended routine adult immunizations
ideally need to be administered prior to
pregnancy
Pregnant women should receive appropriate
vaccines as indicated by age or risk factor
A caution is that some vaccines are
contraindicated in pregnancy

5. VACCINES RECOMMENDED IN PREGNANCY
ROUTINELY RCOMMENDED
•Influenza
•Tdap
•RSV
•COVID
Travel purposes
Anthrax
Polio
JE
RABIES
Typhoid
Yellow fever
Special Circumstances
HAB
HBV
Hib
Pneumococcal
Meningococcal
CONTRAINDICATED IN PREGNANCY
 HPV
 VACCINIA
BEFORE AND AFTER PREGNANCY
MMR
Varicella
CONTRAINDICATED DURING BREAST
FEEDING
Smallpox vaccine and yellow fever vaccine

6. INFLUENZA-IIV
ACOG, the Society for Maternal and Fetal Medicine (SMFM), CDC and ACIP continue to
recommend influenza immunization in each pregnancy to be administered in any trimester
•Recommended for all pregnant women as part of routine prenatal care in each pregnancy during
influenza season.
•Influenza immunization should be offered as early as possible during flu season and can be
administered in any trimester
•Live-attenuated influenza vaccine (LAIV) is not recommended for any age group or population
Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases (NCIRD). Flu Vaccination & Possible Safety
Signal.Centers for Disease Control and Prevention, Influenza (Flu). Available at https://www.cdc.gov/flu/professionals/vaccination/vaccination-
possible-safety-signal.html.
Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases. Department of Health and Human
Services Letter. Centers for Disease Control and Prevention, Influenza (Flu). Available at https://www.cdc.gov/flu/pdf/professionals/pregnant-
women-letter_september-2017-2018.pdf. September 26, 2017; .
American Congress of Obstetricians and Gynecologist. Practice Advisory: Influenza Vaccination During Pregnancy. American College of
Obstetricians and Gynecologist. Available at https://www.acog.org/About-ACOG/News-Room/Practice-Advisories/Practice-Advisory-Influenza-
Vaccination-During-Pregnancy. 2017

7. RATIONALE OF IIV IN PREGNANCY
Four times as likely to be hospitalized with laboratory-confirmed influenza virus in
2009 compared with the general population
Though pregnant women represent only 1% of the US population, they accounted for
5.9% of ICUadmissions and 5.7% of deaths associated with the 2009 H1N1 influenza
virus
Novel Influenza A (H1N1) Pregnancy Working Group. H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet.
2009 Aug 8. 374 (9688):451-8

8. FETAL & INFANT OUTCOME – POST IIV VACCINE
 Decreased Preterm rate, SGA
 Higher mean birth weight
 Reduces ILI in the first 6 months of life.
 Decreased birth defects –due to less febrile episodes
Tapia MD, Sow SO, Tamboura B, et al. Maternal immunisation with trivalent inactivated influenzavaccine for prevention of influenza in
infants in Mali: a prospective, active-controlled, observer-blind, randomised phase 4 trial. Lancet Infect Dis. 2016 Sep. 16 (9):1026-
1035
Acs N, Bánhidy F, Puhó E, Czeizel AE. Pregnancy complications and delivery outcomes of pregnant women with influenza. J Matern Fetal
Neonatal Med. 2006 Mar. 19 (3):135-40.
Oster ME, Riehle-Colarusso T,Alverson CJ, Correa A.Associations between maternal fever and influenza and congenital heart defects. J
Pediatr. 2011 Jun. 158 (6):990-5

9. SAFETY FOR INFANT
A large randomized control trial in Bangladesh found that maternal
immunization reduced influenza-like illnesses (ILI) by 63% in the first 6
months of life
The efficacy of influenza vaccine in pregnancy was corroborated by a trial in
Mali that demonstrated a 64.5 % reduction in influenza A infection in the
first 5 months of life among mothers vaccinated in the third trimester.
Steinhoff MC, Omer SB, Roy E, El Arifeen S, Raqib R, Dodd C, et al. Neonatal outcomes after influenza immunization
during pregnancy: a randomized controlled trial. CMAJ. 2012 Apr 3. 184 (6):645-53

10. ACOG RECOMMENDATIONS for Tdap
All pregnant women should receive (Tdap) vaccine during each pregnancy, as early in the 27–36-
weeks-of-gestation window as possible
If Td booster is indicated at any time in pregnancy, pregnant women should be given Tdap
Women with incomplete or unknown tetanus vaccination status, the tetanus and reduced diphtheria
toxoid (Td) series should be initiated in pregnancy to protect against maternal and neonatal
tetanus. The recommended timeline is 0 weeks, 4 weeks and 6-12 months. One of these doses
should be replaced with Tdap, ideally between 27 and 36 weeks gestation.

11. Rationale of Tdap
Lower rates of stillbirth, neonatal death, hypertensive diseases of pregnancy and low birth weight
Mortality in neonate with pertussis- high - 7 in 10 deaths from whooping cough are
among babies younger than 2 months old.
Tdap during gestational weeks 27 through 36 weeks is 85% more effective < 2months
Postpartum Tdap administration only provides protection to the mother
Sukumaran L, McCarthy NL, Kharbanda EO, Weintraub ES, Vazquez-Benitez G, McNeil MM, et al. Safety of Tetanus Toxoid, Reduced
Diphtheria Toxoid, and Acellular Pertussis and Influenza Vaccinations in Pregnancy. Obstet Gynecol. 2015 Nov. 126 (5):1069-
74.
Munoz FM, Bond NH, Maccato M, Pinell P, Hammill HA, Swamy GK, et al. Safety and immunogenicity of tetanus diphtheria and
acellular pertussis (Tdap) immunization during pregnancy in mothers and infants: a randomized clinical trial. JAMA. 2014
May 7. 311 (17):1760-9.

12. Rationale of Tdap
• Severe pertussis mainly occurred in children aged < 3 months. The
mortality of severe pertussis was 34.2%, with patients younger than
6 weeks accounting for the majority of the deaths.
• Tdap should NOT be offered as part of routine preconception care
• Shi, T., Wang, L., Du, S. et al. Mortality risk factors among hospitalized children with severe
pertussis. BMC Infect Dis 21, 1057 (2021). https://doi.org/10.1186/s12879-021-06732

13. Tdap-efficasy – 90=95%
Rationale of Tdap
Morbidity and mortality from
pertussis in
disproportionately affect
infants 3 months of age and
younger, more than half of
whom are exposed to
pertussis from an infected
parent.
Cocooning – not helpful
A retrospective study found
maternal vaccination in the third
trimester to be 90% effective for
infants under 2 months , results that
were consistent with a case-control
study in England and Wales that
demonstrated 93% effectiveness
and a retrospective cohort in
California demonstrating 91%
effectiveness.

14. COVID VACCINE
• Everyone ages 6 months and older is recommended to get the
updated COVID-19 vaccine.
• This includes people who are pregnant, breastfeeding, trying to
get pregnant now, or those who might become pregnant in the
future
• Infants ages 6 months and older are recommended to get the
updated COVID-19 vaccine even if born to people who were
vaccinated or had COVID-19 before or during pregnancy

15. COVID-19 in Pregnancy
• Although the overall risk of severe illness is low, pregnant people with COVID-19
are at a higher risk of severe disease than nonpregnant people.
• Pregnant women have significantly higher rates;
• Intensive care unit (ICU) admission (10.5 vs. 3.9 cases per 1,000 cases; adjusted
risk ratio [aRR] 3.0; 95% CI, 2.6–3.4)
• Mechanical ventilation (2.9 vs. 1.1 cases per 1,000 cases; aRR 2.9; 95% CI, 2.2–
3.8)
• Extracorporeal membrane oxygenation (0.7 vs. 0.3 cases per 1,000 cases; aRR
2.4; 95% CI, 1.5–4.0), and death (1.5 vs. 1.2 cases per 1,000 cases; aRR 1.7; 95%
CI

16. Obstetric and Perinatal Outcomes in COVID-19
Adverse perinatal outcomes were more common in patients with
severe or critical disease than in asymptomatic patients with
SARS-CoV-2 infection
• Increased incidence of cesarean delivery (59.6% vs. 34.0% of patients;
aRR 1.57; 95% CI, 1.30–1.90)
• Hypertensive disorders of pregnancy (40.4% vs. 18.8%; aRR 1.61; 95%
CI, 1.18–2.20)
• Preterm birth (41.8% vs. 11.9%; aRR 3.53; 95% CI, 2.42–5.1
Metz TD, Clifton RG, Hughes BL, et al. Disease severity and perinatal outcomes of
pregnant patients with coronavirus disease 2019 (COVID-19). Obstet Gynecol.
2021;137(4):571-580.

17. 2023–2024 updated COVID-19 vaccines
• As of October 3, 2023, the 2023-2024 updated
Novavax vaccine
• As of September 12, 2023, the 2023–2024 updated
Pfizer-BioNTech
Moderna COVID-19 vaccines
• The 2023–2024 updated COVID-19 vaccines more
closely targets the XBB lineage of the Omicron variant

19. Respiratory syncytial virus
Respiratory syncytial virus (RSV) or
human respiratory syncytial virus
(hRSV)
Single-stranded RNA virus -
orthopneumovirus
Named so -large cells- syncytia that form
when infected cells fuse
RSV affects an estimated 64 million
people and causes 160,000 deaths
FDA - approval of the vaccine in
February 2023
RSV discovered in 1956- Chimpanzee coryza
agent (CCA). In 1957,same virus was
identified by Robert M. Chanock in
children
Mild upper respiratory tract infections (URTI)
to severe and potentially life-threatening
lower respiratory tract infections (LRTI)
requiring hospitalization and mechanical
ventilation
Presentation often varies between age
groups and immune status.
Reinfection is common throughout life, but
infants and the elderly remain at risk for
symptomatic infection.

20. Respiratory syncytial virus
SEASONAL VARIATION
Filamentous RSV PARTICLES

21. RSV structure and genome organization Phylogenetic tree of the pneumovirus and
paramyxovirus families

22. RSV is divided into two antigenic
subtypes, A and B, based on
the reactivity of the F and G
surface proteins to
monoclonal antibodies.
To date, 16 RSVA and 22
RSVB clades have been
identified
F and G glycoproteins are the
two major surface proteins
that control viral
attachment and the initial
stages of infection. F and G
proteins are also the
primary targets for
neutralizing antibodies
Subtype A more prevalent
&virulent than RSV
subtype B
It has 10 genes
encoding for 11
proteins.The gene order
is NS1-NS2-N-P-M-SH-G-
F-M2-L, with the NS1
and NS2
protein F (fusion protein) is
responsible for fusion of
viral and host cell
membranes, as well as
syncytium formation
between viral particles
It has 1encoding for 11 protorder is NS1-NS2-N-P-M-SH-G-F-M2-L, with the NS1 and NS2 g

23. Risk factors for
progression to lower
respiratory infection
with RSV
Low birth weight
Male sex
Having older siblings
Maternal smoking during pregnancy
History of atopy (tendency to develop
allergic diseases)
No breastfeeding
Household crowding
Congenital heart or lung disease

24. Burden of RSV disease- Why vaccine?
• By 2 years of age, virtually all children will have been infected
• Incidence has been reported to be about 11% to 15%.
• At least 5 hospitalizations for every 1000 children
• 34 million acute lower respiratory tract infections due to RSV
• 3 million severe cases requiring hospitalization,
• 66,000 to 199,000 fatalities,
• 99% of which are in low- and middle-income countries (LMICs

25. Prevention measures for RSV
The main include hand-washing
Avoiding close contact infected individuals
RSV vaccines Arexvy ( GSK ) Abrysvo (Pfizer)
Monoclonal Antibodies palivizumab or nirsevimab (both are treatments) can
prevent RSV infection in high-risk infant

26. Why it took so long for the vaccine- first vaccine in
1960
Vaccine development efforts had previously been slowed
following reports from clinical trials conducted in the 1960s,
in which a formalin-inactivated whole virus vaccine
(FI-RSV) led to enhanced RSV disease (ERD) in
children who subsequently were naturally infected for the
first time with RSV. While the pathogenesis of ERD is not
completely understood, strategies have been developed to
reduce the risk and support further candidate vaccine
development.

28. RSV fusion (F) protein
One turning point came with the investigation
of an RSV protein called “RSV fusion (F)”
that provided potent stimulation to the
immune system—research that paved the
way to clinical trials

29. FDA Approves First Vaccine for Pregnant Individuals to Prevent RSV in
Infants
August 21, 2023
Today, the U.S. Food and Drug Administration approved Abrysvo
(Respiratory Syncytial Virus Vaccine), the first vaccine
approved for use in pregnant individuals to prevent lower
respiratory tract disease (LRTD) and severe LRTD caused by
respiratory syncytial virus (RSV) in infants from birth through
6 months of age. Abrysvo is approved for use at
32 through 36 weeks gestational age of
pregnancy.

30. RSV vaccine (Abrysvo)
• Vial of Lyophilized Antigen
Component (a sterile white
powder)
• Prefilled syringe containing
Sterile Water Diluent
Component
• Store vaccine and diluent
2°C and 8°C (36°F and 46°F)
• Store these components in
their original package and
keep them together
• Never freeze the vaccine or
diluent.

31. RSV vaccine (Abrysvo)
ACOG and The Society for Maternal-Fetal Medicine recommends
seasonal administration of a single dose of RSV vaccine (Abrysvo)
for pregnant individuals between 32 0/7 and 36 6/7 weeks of
gestation
RSV seasons can vary in different parts of the world- timing
important
Guideline] American College of Obstetricians and Gynecologists. Maternal Respiratory Syncytial Virus Vaccination. ACOG.
Available at https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2023/09/maternal-respiratory-
syncytial-virus-vaccination. 2023 Sep; updated 2023 Oct 10;

32. MATernal Immunization Study for Safety and Efficacy (MATISSE), 3682
maternal participants received vaccine and 3676 received placebo; 3570 and
3558 infants, respectively, were evaluated. Medically attended severe lower
respiratory tract illness occurred within 90 days after birth in 6 infants of
women in the vaccine group and 33 infants of women in the placebo group
(vaccine efficacy, 81.8%); 19 cases and 62 cases, respectively, occurred
within 180 days after birth (vaccine efficacy, 69.4%)

33. Abrysvo Vs Arexvy
Abrysvo contains the F protein from both types
and in indicated during pregnancy
Arexvy only contains a single F protein i.e Type
A only

35. Hepatitis A- ACIP and ACOG advise
Pregnancy is not a contraindication and HAV vaccine in pregnancy for women in whom the risk
of HAV infection exceeds the theoretical risk of immunization or pregnant women travel to
areas where there is an increased risk for exposure to hepatitis A
Pregnant women who have been exposed to individuals with HAV infection and have not previously
been immunized should receive post-exposure prophylaxis . pregnant women should receive both
immune globulin and HAV immunization as soon as possible after exposure
Advisory Committee on Immunization Practices (ACIP)., Fiore AE, Wasley A, Bell BP. Prevention of hepatitis A through active or passive
immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006 May 19. 55
(RR-7):1-23. [QxMD MEDLINE Link].
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 86: Viral hepatitis in pregnancy. Obstet Gynecol. 2007 Oct.
110 (4):941-56

36. Caution for HAV
The safety of HAV immunization in pregnancy has not been
determined; however, hepatitis A vaccine is an inactivated vaccine
with extremely low potential for maternal or fetal harm

37. Hepatitis B VACCINE
• ACIP and ACOG recommend HBV immunization for pregnant women at risk of infection
• Pregnancy is not a contraindication to hepatitis B vaccine
• Routine prenatal screening for HBsAg is recommended to detect HBV carriers and to ensure neonatal
immunoprophylaxis at birth if needed
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 86: Viral hepatitis in pregnancy. Obstet Gynecol. 2007
Oct. 110 (4):941-56.
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 86: Viral hepatitis in pregnancy. Obstet Gynecol. 2007 Oct.
110 (4):941-56. [QxMD MEDLINE Link].
Mast EE, Weinbaum CM, Fiore AE, Alter MJ, Bell BP, Finelli L, et al. A comprehensive immunization strategy to eliminate transmission of
hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II:
immunization of adults. MMWR Recomm Rep. 2006 Dec 8. 55 (RR-16):1-33; quiz CE1

38. Haemophilus influenzae type B (Hib)
Due to both limited data and limited use of this vaccine in pregnancy, there is
currently no recommendation from the CDC or ACIP on the use of Hib
immunization in pregnancy
Initial small studies on Hib administration in the third trimester
demonstrated safety for both pregnant women and their infants
Rasmussen SA, Watson AK, Kennedy ED, Broder KR, Jamieson DJ. Vaccines and pregnancy: past, present, and future. Semin Fetal
Neonatal Med. 2014 Jun. 19 (3):161-9.

39. Meningococcal conjugate vaccines (MCV4 and MenACWY)
• ACIP recommends that pregnant women at increased risk for meningococcal
disease be immunized according to existing adult recommendations
• Though no risks of immunization have been identified, the potential risk of
disease exposure should be balanced against the theoretical risk of vaccine
administration
Makris MC, Polyzos KA, Mavros MN, Athanasiou S, Rafailidis PI, Falagas ME. Safety of hepatitis B,
pneumococcal polysaccharide and meningococcal polysaccharide vaccines in pregnancy: a systematic
review
Centers for Disease Control and Prevention. Pregnancy and Vaccination, Guidelines and Recommendations by
Vaccine. Centers for Disease Control and Prevention, Vaccines. Available at
https://www.cdc.gov/vaccines/pregnancy/hcp/guidelines.html.

40. Pneumococcal polysaccharide (PPSV23)
Pregnancy is not a contraindication to immunization
ACIP recommends that pregnant women with medical risk factors for
invasive pneumococcal disease be immunized with PPSV23 in
pregnancy.
The safety of pneumococcal immunization in the first trimester has not been
established, though no adverse events have been reported
No guideline has been published regarding the use of PCV13 in pregnancy
Centers for Disease Control and Prevention (CDC)., Advisory Committee on Immunization Practices. Updated recommendations for prevention of
invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR Morb Mortal Wkly Rep.
2010 Sep 3. 59 (34):1102-6.

41. Anthrax Vaccine Adsorbed (AVA)
• Post-exposure AVA immunization, where the benefit greatly outweighs the theoretical risk of
immunization, is recommended for all individuals exposed to anthrax including pregnant women
• Given the low-risk of anthrax exposure, pre-event immunization is not recommended for pregnant
women, as the benefit of immunization does not outweigh the theoretical risk of immunization
• Conlin AM, Bukowinski AT, Gumbs GR, Department of Defense Birth and Infant Health Registry Team. Analysis of pregnancy and infant health
outcomes among women in the National Smallpox Vaccine in Pregnancy Registry who received Anthrax Vaccine Adsorbed. Vaccine. 2015 Aug 26. 33
(36):4387-90.

42. Japanese encephalitis
• ACIP has no recommendation regarding JE immunization in pregnancy. Due to the lack of
safety data, JE immunization should generally be avoided in pregnant women
• Pregnant women traveling to endemic areas for extended periods should be considered for
immunization with an inactivated vaccine if the theoretical risk of immunization is
outweighed by the risk of JE virus infection
Bielefeldt-Ohmann H, Prow NA, Wang W, Tan CS, Coyle M, Douma A, et al. Safety and immunogenicity of a delta inulin-adjuvanted
inactivated Japanese encephalitis virus vaccine in pregnant mares and foals. Vet Res. 2014 Dec 17. 45:130

43. Polio
• Pregnancy is a precaution to immunization with inactivated polio vaccine (IPV)
• IPV may be administered to pregnant women. ACIP recommends that inactivated polio
vaccine (IPV) be considered for pregnant women at risk for exposure to wild-type
poliovirus.
Several mass immunization programs in Finland and Israel that reached >90% of the
population and included pregnant women revealed no safety concerns for pregnant
women or their fetuses following immunization with OPV.

44. Rabies-recommendation
• Pregnancy is not a contraindication to rabies immunization
• Pregnant women should follow the adult immunization guidelines for rabies
• Post-exposure immunization is recommended for all pregnant women
• Pregnant women at high risk for rabies exposure should be considered for pre-exposure
immunization
Limited small observational studies have found no association between maternal rabies immunization and
spontaneous abortion, preterm birth or teratogenesis

45. Typhoid
• The CDC does not make any specific recommendations for typhoid immunization
in pregnancy and no data is available on the safety of the inactivated typhoid
vaccine in pregnancy
• In general, pregnant women are advised to avoid travel to areas with high rates
of endemic typhoid
• Immunization with the inactivated vaccine may be considered if the risk of
acquiring the disease significantly outweighs theoretical risks of immunization
• The live attenuated typhoid vaccine (Ty21a) should not be administered in
pregnancy due to theoretical risks posed by live vaccines.

46. Breastfeeding and Vaccines
• The two vaccines that are generally not recommended for breastfeeding mothers are smallpox vaccine and
yellow fever vaccine
• Smallpox immunization presents the risk of person to person transmission through direct contact, and is
therefore contraindicated for breastfeeding mothers due to the theoretical concern for direct horizontal
transmission to the infant.
• Breastfeeding is a precaution for yellow fever vaccination due to two reports of yellow fever vaccine-
associated neurologic disease (YEL-AND) in breastfed infants

47. Contraindicated in Pregnancy
• Human papillomavirus (HPV
• Vaccinia (smallpox)
• HPV vaccination with the 9-valent HPV vaccine is routinely recommended
for adolescents aged 11 years or 12 years, and for adults through age 45
years who were inadequately vaccinated previously.
• Early data on inadvertent HPV vaccination in pregnancy are reassuring,
and there is no recommendation for pregnancy testing prior to HPV
vaccine administration. No differences in pregnancy complications or
major birth defects were noted after administration of the 4-valent HPV
vaccine
• Smallpox vaccine has been known to cause fetal infection with fetal
vaccinia.

48. Yellow Fever Vaccine
• Pregnancy is a precaution for yellow fever
vaccination
• Pregnant women at high-risk for acquiring
yellow fever should receive yellow-fever
vaccine as the theoretical risk of immunization
is outweighed by the risk for yellow fever
infection
• Pregnant and nursing women traveling to low-

49. Adverse effects of yellow fever Vaccine
Serious adverse events
• hypersensitivity or anaphylaxis
• Yellow fever vaccine-associated
neurologic disease (YEL-AND)
• Yellow fever associated viscerotropic
disease (YEL-AVD) which is
characterized by multiorgan failure.
YEL-AND
• Breastfeeding is also a
precaution for yellow fever
immunization as two cases,
one probable and one
confirmed, of YEL-AND
have been described in
breastfeeding infants
whose mothers received
yellow fever vaccine.

50. SUMMARY
•Maternal immunization
has been demonstrated to
be a safe and effective.
•Influenza vaccine is
recommended in each
pregnancy and can be
administered in any
trimester.
Tdap is recommended in
every pregnancy, between
27 and 36 weeks of
gestation
Other vaccines may be
indicated in special
circumstances, due to
medical comorbidities,

51. Thanks