No. 357-Immunization in Pregnancy

Published:March 02, 2018DOI:



      To review the evidence and provide recommendations on immunization in pregnancy.


      Outcomes evaluated include effectiveness of immunization and risks and benefits for mother and fetus.


      The Medline and Cochrane databases were searched for articles published up to January 2017 on the topic of immunization in pregnancy.


      The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1).

      Benefits, Harms, and Costs

      Implementation of the recommendations in this guideline should result in more appropriate immunization of pregnant and breastfeeding women, decreased risk of contraindicated immunization, and better disease prevention.


      • 1.
        Health care providers should obtain a relevant immunization history from all women accessing prenatal care and offer vaccinations as indicated (III-A).
      • 2.
        In general, live and/or live-attenuated virus vaccines should not be administered during pregnancy because there is a largely theoretical risk to the fetus (II-3B).
      • 3.
        Women who have inadvertently received vaccination with a live or live-attenuated vaccine during pregnancy should not be counselled to terminate the pregnancy for the reason of a teratogenic risk (II-2A).
      • 4.
        Non-pregnant women receiving a live or live-attenuated vaccine should be counselled to delay pregnancy for at least 4 weeks (III-B).
      • 5.
        Inactivated viral vaccines, bacterial vaccines, and toxoids can be used safely in pregnancy (II-1A).
      • 6.
        Breastfeeding is not a contraindication to vaccination (passive-active immunization, live, with the exception of yellow fever, or killed vaccines) (II-1A).
      • 7.
        All pregnant women should be offered the diphtheria and tetanus toxoids and acellular pertussis vaccine during the second or third trimester, preferably between 21 and 32 weeks gestation, during every pregnancy, irrespective of their immunization history (II-2A).
      • 8.
        All pregnant women, at any stage in pregnancy, or women who might be pregnant in the upcoming influenza season, should be offered the inactivated influenza vaccine for the prevention of maternal and infant influenza-related morbidity and mortality (I-1A).
      • 9.
        Pregnant women with suspected or documented influenza infection, regardless of immunization history, should be treated with oseltamivir (Tamiflu, 75 mg po twice daily) (III-B).
      • 10.
        Some pregnant women should be offered the hepatitis B, hepatitis A, meningococcal, and/or pneumococcal vaccines for the prevention of maternal morbidity if they have specific risk factors by means of their medical comorbidities or specific exposures (III-A).

      Key Words


      CRS (congenital rubella syndrome), GBS (Guillain-Barré syndrome), HIV (human immunodeficiency virus), HPV (human papilloma virus), IPD (invasive pneumococcal disease), MMR (measles, mumps, rubella), RCT (randomized controlled trial), Td (tetanus toxoids and diphtheria vaccine), Tdap (tetanus toxoids, diphtheria and acellular pertussis vaccine), WHO (World Health Organization)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Obstetrics and Gynaecology Canada
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Castillo E.
        • Murphy K.
        • van Schalkwyk J.
        No. 342-Hepatitis B and pregnancy.
        J Obstet Gynaecol Can. 2017; 39: 181-190
        • Macdonald N.
        • Bortolussi R.
        A harmonized immunization schedule for Canada: a call to action.
        Paediatr Child Health. 2011; 16: 29-31
        • Halperin B.A.
        • MacKinnon-Cameron D.
        • McNeil S.
        • et al.
        Maintaining the momentum: key factors influencing acceptance of influenza vaccination among pregnant women following the H1N1 pandemic.
        Hum Vaccin Immunother. 2014; 10: 3629-3641
        • Blanchard-Rohner G.
        • Meier S.
        • Ryser J.
        • et al.
        Acceptability of maternal immunization against influenza: the critical role of obstetricians.
        J Matern Fetal Neonatal Med. 2012; 25: 1800-1809
        • Laenen J.
        • Roelants M.
        • Devlieger R.
        • et al.
        Influenza and pertussis vaccination coverage in pregnant women.
        Vaccine. 2015; 33: 2125-2131
        • Healy C.M.
        • Rench M.A.
        • Montesinos D.P.
        • et al.
        Knowledge and attitiudes of pregnant women and their providers towards recommendations for immunization during pregnancy.
        Vaccine. 2015; 33: 5445-5451
        • Munoz F.M.
        • Englund J.A.
        Vaccines in pregnancy.
        Infect Dis Clin North Am. 2001; 15: 253-271
        • Heinonen O.P.
        • Slone D.
        • Shapiro S.
        Immunizing agents.
        in: Heinonen O.P. Slone D. Shapiro S. Birth defects and drugs in pregnancy. Publishing Sciencies Group, Littleton, MA1997: 314-321
        • Watson J.C.
        • Hadler S.C.
        • Dykewicz C.A.
        • et al.
        Measles, mumps, and rubella—vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP).
        MMWR Recomm Rep. 1998; 47: 1-57
        • McLean H.Q.
        • Fiebelkorn A.P.
        • Temte J.L.
        • et al.
        • Centers for Disease Control and Prevention
        Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP).
        MMWR Recomm Rep. 2013; 62: 1-34
        • Zealley H.
        • Edmond E.
        Rubella screening and immunisation of schoolgirls: results six to seven years after vaccination.
        Br Med J (Clin Res Ed). 1982; 284: 382-384
        • Mortimer P.P.
        • Edwards J.M.
        • Porter A.D.
        • et al.
        Are many women immunized against rubella unnecessarily?.
        J Hyg (Lond). 1981; 87: 131-138
        • Public Health Agency of Canada
        Canadian immunization guide: part 1—Key Immunization Information.
        (Ottawa: Public Health Agency of Canada; Available at:)
        • Gershon A.A.
        Chicken pox, measles and mumps.
        in: Remington J.S. Klein J.O. Infectious diseases of the fetus and newborn infant. WB Saunders, Philadelphia2001: 683
        • Harger J.H.
        • Ernest J.M.
        • Thurnau G.R.
        • et al.
        Frequency of congenital varicella syndrome in a prospective cohort of 347 pregnant women.
        Obstet Gynecol. 2002; 100: 260-265
        • DeNicola L.K.
        • Hanshaw J.B.
        Congenital and neonatal varicella.
        J Pediatr. 1979; 94: 175-176
        • Public Health Agency of Canada
        Varicella (chickenpox) vaccine.
        Public Health Agency of Canada, Ottawa2016 (Available at)
        • Shields K.E.
        • Galil K.
        • Seward J.
        • et al.
        Varicella vaccine exposure during pregnancy: data from the first 5 years of the pregnancy registry.
        Obstet Gynecol. 2001; 98: 14-19
        • Cavalcanti D.P.
        • Salomao M.A.
        • Lopez-Camelo J.
        • et al.
        • Campinas Group of Yellow Fever Immunization during Pregnancy
        Early exposure to yellow fever vaccine during pregnancy.
        Trop Med Int Health. 2007; 12: 833-837
        • Public Health Agency of Canada
        Pertussis (whooping cough).
        Public Health Agency of Canada, Ottawa2014 (Available at)
        • Amirthalingam G.
        • Gupta S.
        • Campbell H.
        Pertussis immunisation and control in England and Wales, 1957 to 2012: a historical review.
        Euro Surveill. 2013; 18
        • Gall S.A.
        • Myers J.
        • Pichichero M.
        Maternal immunization with tetanus-diphtheria-pertussis vaccine: effect on maternal and neonatal serum antibody levels.
        Am J Obstet Gynecol. 2011; 204: e1-e5
        • Maertens K.
        • Cabore R.N.
        • Huygen K.
        • et al.
        Pertussis vaccination during pregnancy in Belgium: results of a prospective controlled cohort study.
        Vaccine. 2016; 34: 142-150
        • Abu Raya B.
        • Srugo I.
        • Kessel A.
        • et al.
        The effect of timing of maternal tetanus, diphtheria, and acellular pertussis (Tdap) immunization during pregnancy on newborn pertussis antibody levels—a prospective study.
        Vaccine. 2014; 32: 5787-5793
        • Eberhardt C.S.
        • Blanchard-Rohner G.
        • Lemaitre B.
        • et al.
        Maternal immunization earlier in pregnancy maximizes antibody transfer and expected infant seropositivity against pertussis.
        Clin Infect Dis. 2016; 62: 829-836
        • Calvert A.
        • Jones C.E.
        Placental transfer of antibody and its relationship to vaccination in pregnancy.
        Curr Opin Infect Dis. 2017; 30: 268-273
        • Healy C.M.
        • Rench M.A.
        • Baker C.J.
        Importance of timing of maternal combined tetanus, diphtheria, and acellular pertussis (Tdap) immunization and protection of young infants.
        Clin Infect Dis. 2013; 56: 539-544
        • Naidu M.A.
        • Muljadi R.
        • Davies-Tuck M.L.
        • et al.
        The optimal gestation for pertussis vaccination during pregnancy: a prospective cohort study.
        Am J Obstet Gynecol. 2016; 215 (e1-6): 237
        • Abu Raya B.
        • Srugo I.
        • Bamberger E.
        Optimal timing of immunization against pertussis during pregnancy.
        Clin Infect Dis. 2016; 63: 143-144
        • Vilajeliu A.
        • Gonce A.
        • Lopez M.
        • et al.
        Combined tetanus-diphtheria and pertussis vaccine during pregnancy: transfer of maternal pertussis antibodies to the newborn.
        Vaccine. 2015; 33: 1056-1062
        • Ladhani S.N.
        • Andrews N.J.
        • Southern J.
        • et al.
        Antibody responses after primary immunization in infants born to women receiving a pertussis-containing vaccine during pregnancy: single arm observational study with a historical comparator.
        Clin Infect Dis. 2015; 61: 1637-1644
        • Abu Raya B.
        • Bamberger E.
        • Almog M.
        • et al.
        Immunization of pregnant women against pertussis: the effect of timing on antibody avidity.
        Vaccine. 2015; 33: 1948-1952
        • Maertens K.
        • Hoang T.H.
        • Cabore R.N.
        • et al.
        Avidity of maternal pertussis antibodies after vaccination during pregnancy.
        Vaccine. 2015; 33: 5489
        • Hoang H.T.
        • Leuridan E.
        • Maertens K.
        • et al.
        Pertussis vaccination during pregnancy in Vietnam: results of a randomized controlled trial Pertussis vaccination during pregnancy.
        Vaccine. 2016; 34: 151-159
        • Hardy-Fairbanks A.J.
        • Pan S.J.
        • Decker M.D.
        • et al.
        Immune responses in infants whose mothers received Tdap vaccine during pregnancy.
        Pediatr Infect Dis J. 2013; 32: 1257-1260
        • Munoz F.M.
        • Bond N.H.
        • Maccato M.
        • 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; 311: 1760-1769
        • Halperin S.
        • Halperin B.
        • Allen V.
        • et al.
        Safety and immunogenicity of tetanus-diphtheria-acellular pertussis vaccine (Tdap) during pregnancy.
        (Presented at; Canadian Immunization Conference. Ottawa; December 6–8)2016
        • Winter K.
        • Nickell S.
        • Powell M.
        • et al.
        Effectiveness of prenatal versus postpartum tetanus, diphtheria, and acellular pertussis vaccination in preventing infant pertussis.
        Clin Infect Dis. 2017; 64: 3-8
        • Baxter R.
        • Bartlett J.
        • Fireman B.
        • et al.
        Effectiveness of vaccination during pregnancy to prevent infant pertussis.
        Pediatrics. 2017; 139: e20164091
        • Amirthalingam G.
        • Campbell H.
        • Ribeiro S.
        • et al.
        Sustained effectiveness of the maternal pertussis immunization program in England 3 years following introduction.
        Clin Infect Dis. 2016; 63: S236-S243
        • Dabrera G.
        • Amirthalingam G.
        • Andrews N.
        • et al.
        A case-control study to estimate the effectiveness of maternal pertussis vaccination in protecting newborn infants in England and Wales, 2012–2013.
        Clin Infect Dis. 2015; 60: 333-337
        • Amirthalingam G.
        • Andrews N.
        • Campbell H.
        • et al.
        Effectiveness of maternal pertussis vaccination in England: an observational study.
        Lancet. 2014; 384: 1521-1528
        • Kharbanda E.O.
        • Vazquez-Benitez G.
        • Lipkind H.S.
        • et al.
        Evaluation of the association of maternal pertussis vaccination with obstetric events and birth outcomes.
        JAMA. 2014; 312: 1897-1904
        • National Advisory Committee on Immunization
        Summary of the NACI update on immunization in pregnancy with tetanus toxoid, reduced diphtheria toxoid and reduced acellular pertussis (Tdap) vaccine.
        Can Commun Dis Rep. 2018; 44: 91-94
        • Walls T.
        • Graham P.
        • Petousis-Harris H.
        • et al.
        Infant outcomes after exposure to Tdap vaccine in pregnancy: an observational study.
        BMJ Open. 2016; 6: e009536
        • Talbot E.A.
        • Brown K.H.
        • Kirkland K.B.
        • et al.
        The safety of immunizing with tetanus-diphtheria-acellular pertussis vaccine (Tdap) less than 2 years following previous tetanus vaccination: experience during a mass vaccination campaign of healthcare personnel during a respiratory illness outbreak.
        Vaccine. 2010; 28: 8001-8007
        • World Health Organization
        Pertussis vaccines: WHO position paper, August 2015—recommendations.
        Vaccine. 2016; 34: 1423-1425
        • Harris J.W.
        Influenza occurring in pregnant women: a statistical study of thirteen hundred and fifty cases.
        JAMA. 1919; 72: 980
        • Freeman D.W.
        • Barno A.
        Deaths from Asian influenza associated with pregnancy.
        Am J Obstet Gynecol. 1959; 78: 1172-1175
        • Neuzil K.M.
        • Reed G.W.
        • Mitchel E.F.
        • et al.
        Impact of influenza on acute cardiopulmonary hospitalizations in pregnant women.
        Am J Epidemiol. 1998; 148: 1094-1102
        • Cox S.
        • Posner S.F.
        • McPheeters M.
        • et al.
        Hospitalizations with respiratory illness among pregnant women during influenza season.
        Obstet Gynecol. 2006; 107: 1315-1322
        • Cox S.
        • Posner S.F.
        • McPheeters M.
        • et al.
        Influenza and pregnant women: hospitalization burden, United States, 1998–2002.
        J Womens Health (Larchmt). 2006; 15: 891-893
        • Dodds L.
        • McNeil S.A.
        • Fell D.B.
        • et al.
        Impact of influenza exposure on rates of hospital admissions and physician visits because of respiratory illness among pregnant women.
        CMAJ. 2007; 176: 463-468
        • Schanzer D.L.
        • Langley J.M.
        • Tam T.W.
        Influenza-attributed hospitalization rates among pregnant women in Canada 1994–2000.
        J Obstet Gynaecol Can. 2007; 29: 622-629
        • MacDonald N.E.
        • Riley L.E.
        • Steinhoff M.C.
        Influenza immunization in pregnancy.
        Obstet Gynecol. 2009; 114: 365-368
        • Zaman K.
        • Roy E.
        • Arifeen S.E.
        • et al.
        Effectiveness of maternal influenza immunization in mothers and infants.
        N Engl J Med. 2008; 359: 1555-1564
        • Centers for Disease Control and Prevention
        Novel influenza A (H1N1) virus infections in three pregnant women—United States, April–May 2009.
        MMWR Morb Mortal Wkly Rep. 2009; 58: 497-500
        • Kharbanda E.O.
        • Vazquez-Benitez G.
        • Romitti P.A.
        • et al.
        First trimester influenza vaccination and risks for major structural birth defects in offspring.
        J Pediatr. 2017; 187 (e4): 234-239
        • Moro P.
        • Baumblatt J.
        • Lewis P.
        • et al.
        Surveillance of adverse events after seasonal influenza vaccination in pregnant women and their infants in the Vaccine Adverse Event Reporting System, July 2010–May 2016.
        Drug Saf. 2017; 40: 145-152
        • Bratton K.N.
        • Wardle M.T.
        • Orenstein W.A.
        • et al.
        Maternal influenza immunization and birth outcomes of stillbirth and spontaneous abortion: a systematic review and meta-analysis.
        Clin Infect Dis. 2015; 60: e11-e19
        • Chambers C.D.
        • Johnson D.L.
        • Xu R.
        • et al.
        Safety of the 2010–11, 2011–12, 2012–13, and 2013–14 seasonal influenza vaccines in pregnancy: birth defects, spontaneous abortion, preterm delivery, and small for gestational age infants, a study from the cohort arm of VAMPSS.
        Vaccine. 2016; 34: 4443-4449
        • Donahue J.G.
        • Kieke B.A.
        • King J.P.
        • et al.
        Association of spontaneous abortion with receipt of inactivated influenza vaccine containing H1N1pdm09 in 2010–11 and 2011–12.
        Vaccine. 2017; 35: 5314-5322
        • Tamma P.D.
        • Ault K.A.
        • del Rio C.
        • et al.
        Safety of influenza vaccination during pregnancy.
        Am J Obstet Gynecol. 2009; 201: 547-552
        • Moro P.L.
        • Broder K.
        • Zheteyeva Y.
        • et al.
        Adverse events in pregnant women following administration of trivalent inactivated influenza vaccine and live attenuated influenza vaccine in the Vaccine Adverse Event Reporting System, 1990–2009.
        Am J Obstet Gynecol. 2011; 204 (e1-7): 146
        • Public Health Agency of Canada
        Vaccine surveillance report—adverse events following immunization.
        Public Health Agency of Canada, Ottawa2010 (Available at)
        • European Medicines Agency
        Fifteenth pandemic pharmacovigilance update.
        European Medicines Agency, London2010 (Available at)
        • Steinhoff M.C.
        • Omer S.B.
        • Roy E.
        • et al.
        Neonatal outcomes after influenza immunization during pregnancy: a randomized controlled trial.
        CMAJ. 2012; 184: 645-653
        • Regan A.K.
        • Moore H.C.
        • de Klerk N.
        • et al.
        Seasonal trivalent influenza vaccination during pregnancy and the incidence of stillbirth: population-based retrospective cohort study.
        Clin Infect Dis. 2016; 62: 1221-1227
        • National Advisory Committee on Immunization
        Statement on influenza vaccination for the 2008–2009 season. An Advisory Committee Statement (ACS).
        Can Commun Dis Rep. 2008; 34: 1-46
        • Jamieson D.J.
        • Honein M.A.
        • Rasmussen S.A.
        • et al.
        H1N1 2009 influenza virus infection during pregnancy in the USA.
        Lancet. 2009; 374: 451-458
        • Mertz D.
        • Kim T.H.
        • Johnstone J.
        • et al.
        Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis.
        BMJ. 2013; 347: f5061
        • Pierce M.
        • Kurinczuk J.J.
        • Spark P.
        • et al.
        Perinatal outcomes after maternal 2009/H1N1 infection: national cohort study.
        BMJ. 2011; 342: d3214
        • Fiore A.E.
        • Fry A.
        • Shay D.
        • et al.
        Antiviral agents for the treatment and chemoprophylaxis of influenza—recommendations of the Advisory Committee on Immunization Practices (ACIP).
        MMWR Recomm Rep. 2011; 60: 1-24
        • Donner B.
        • Niranjan V.
        • Hoffmann G.
        Safety of oseltamivir in pregnancy: a review of preclinical and clinical data.
        Drug Saf. 2010; 33: 631-642
        • Levy M.
        • Koren G.
        Hepatitis B vaccine in pregnancy: maternal and fetal safety.
        Am J Perinatol. 1991; 8: 227-232
        • Grosheide P.M.
        • Schalm S.W.
        • van Os H.C.
        • et al.
        Immune response to hepatitis B vaccine in pregnant women receiving post-exposure prophylaxis.
        Eur J Obstet Gynecol Reprod Biol. 1993; 50: 53-58
        • Dawar M.
        • Dobson S.
        • Deeks S.
        Literature review on HPV 6, 11, 16 and 18: disease and vaccine characteristics.
        Public Health Agency of Canada, Ottawa2007 (Available at)
        • Public Health Agency of Canada
        Canadian immunization guide: part 4—active vaccines. Human papillovirus vaccine.
        Public Health Agency of Canada, Ottawa2016 (Available at)
        • Pacheco L.D.
        • Saad A.F.
        • Hankins G.D.
        • et al.
        Guillain-Barre syndrome in pregnancy.
        Obstet Gynecol. 2016; 128: 1105-1110
        • Vellozzi C.
        • Iqbal S.
        • Broder K.
        Guillain-Barre syndrome, influenza, and influenza vaccination: the epidemiologic evidence.
        Clin Infect Dis. 2014; 58: 1149-1155