Advising Patients on Vaccines During Pregnancy

As respiratory virus season gets under way, family practice and OB-GYN clinicians are likely having more conversations about vaccinations with patients who are pregnant or expecting to become pregnant soon. And while vaccines have found their way into the news more in recent years, the science and evidence has held steady — as have recommendations from the American College of Obstetrics and Gynecology (ACOG).

Consult QD recently interviewed Oluwatosin Goje, MD, MSCR, Medical Director of Cleveland Clinic’s Center for Infant and Maternal Health, to revisit those recommendations and discuss details worth considering during patient counseling. Here’s what she had to say.

Where is the best place for clinicians and patients to start in a discussion about vaccines and pregnancy?

Dr. Goje: Let's start by saying that ACOG has been recommending four vaccines in pregnancy, and their 2025 practice advisory document reaffirms their recommendations. Those are seasonal vaccines for flu, COVID-19, RSV, and then the TDaP — a combination vaccine that protects against tetanus, diphtheria and pertussis, or whooping cough. The TDaP is not seasonal. It can be given at any time of the year.

RSV

Let’s start with the respiratory syncytial virus (RSV). What is important to know?

Dr. Goje: There is only one RSV vaccine that is recommended in pregnancy, and that is Pfizer’s Abrysvo. It should be administered between pregnancy weeks 32 and 36, and between Sept. 1 through January 31, which is the official respiratory virus season in the United States.

The maternal RSV vaccine is a one-time shot, so patients who have received it in previous pregnancies should not get it in this pregnancy. Everything has to be evidence based, and there's no evidence that suggests a second administration will be helpful.

Instead, what ACOG and the U.S. Centers for Disease Control and Prevention (CDC) recommend is that for mothers who previously received the RSV vaccine, their babies be eligible to receive monoclonal antibodies, preferably at birth or within the first week of life. But monoclonal antibodies can be given up to the eighth month of life.

If a mother decides does not receive the maternal RSV vaccine, her doctor and pediatrician should talk to her about her baby receiving the monoclonal antibodies. That is important.

Timing is also important. The maternal RSV vaccine needs at least two weeks post-administration for the antibodies to be developed to transfer to the baby. So if the mother develops a preterm birth, or something changes and the vaccine was given less than two weeks before delivery, then the baby should still get the monoclonal antibodies.

Why is the maternal RSV protection so important?
When studies were done that looked at babies with severe lower respiratory-tract infection, the RSV vaccine decreased it by 81.9% within 90 days after birth and by 69.4% within 180 days after birth. So when we talk about efficacy, this vaccine works.

Most of the vaccine safety concerns are what we have always known, even as non-pregnant people: sore arm, some fever, and pain at the injection site.

What do you tell your patients who would prefer to not get the RSV vaccine while they are pregnant but want their babies to receive the monoclonal antibodies after birth?

The two options are equivalent as far as preventing death or hospitalization or lower respiratory tract infection. If you don’t get the vaccine, however, it means that your baby will have one more vaccine. That's why physician counseling is so important.

The other things to consider about monoclonal antibodies treatment is whether it is available and covered by the patient’s insurance. These newer monoclonal antibodies are bit expensive. So when you are in counseling, you should speak to your patient about both options.

COVID-19

Has the COVID-19 vaccine recommendation become more complicated this year?
It's straightforward, and pregnant women should be vaccinated. Covid is still a problem in pregnancy. It's still an infection that can rapidly deteriorate and be associated with an increased risk of severe disease and poor maternal outcomes.

The evidence is very robust that when you look at nonpregnant women with symptomatic covid and pregnant women with symptomatic covid, the pregnant woman with symptomatic covid has a higher chance of complications.

One of the things we need to consider with our patients who are pregnant and have covid is that in addition to pregnancy, other chronic morbidities also increase risk. So these may include severe obesity, diabetes, hypertension, cardiovascular disease, advanced maternal age — all those in addition to being pregnant and being symptomatic with covid can increase the patient’s risk of a poor outcome.

Now let's look at vaccine safety. During the pandemic, I gave so many interviews about concerns around the COVID-19 vaccine and infertility, changing menstrual periods and miscarriage. There is no evidence that the COVID-19 vaccine causes bad outcomes. We have a lot of retrospective analyses. We have five years of data that shows that the vaccine is safe.

Most of the vaccine side effects that you encounter in pregnant patients are the same thing that other people have, which is pain at injection site, flu-like myalgia, feeling fatigued and things that acetaminophen can take care of. And again, pregnant women who receive the vaccine in the third trimester have an opportunity to transfer some of that immunity to their newborns.

Flu

What about the flu?

People should get a flu vaccine whether or not they are pregnant. And it can be given during any part of the perinatal cycle: postpartum, lactating or any trimester. Pregnant patients who are worried about being vaccinated may need to be reminded that we don’t use live vaccines for flu, covid or the RSV.

The flu vaccine given during the third trimester also may transfer some immunity to the child, so it's a way for mothers to protect their unborn children.

I was a resident during the H1N1 pandemic, and will never forget seeing a mother with twin gestation who had to be intubated. She was struggling to breathe. Once we stabilized her, we had to deliver her.

If you were to encounter a patient very early in a pregnancy as respiratory virus season gets under way, would you counsel her to get these respiratory vaccines now rather than wait until she can confer some of the protection to the baby?

Yes, get it now. Get it now because you need to be alive and healthy to carry to term. Get it now.

TDaP

Do we want to talk about the TDaP?

Unlike the other vaccine’s we’ve discussed, TDaP is unrelated to respiratory virus season and is available to all year around. It’s protective against diphtheria, tetanus and acellular pertussis, or whooping cough.

As we know, pertussis is extremely contagious, and infants are at the most risk for complications. The CDC has noted that pertussis cases dropped during the covid pandemic, probably in response to isolations, lockdowns and masking practices. It was back up against last year, however, and is staying high this year as well.

All of this is to say that we should be counseling our pregnant patients to be vaccinated.

The TDaP is given from 27 weeks of pregnancy to 36, and it's the same principle: Patients getting it in the third trimester transfer IgG antibodies to the baby and give them some protection against whooping cough before they’re eligible to receive the DTaP, which is the version of the vaccine for children and adolescents. Whooping cough is worse in children younger than six months, especially those less than three months. Babies start getting their DTaP around two months.

Some women want to get the TDaP in the postpartum phase, which is possible, but they should be counseled that they are protecting only themselves. Some will talk about cocooning, when all family members who are direct caregivers receive a DTaP to protect the baby. That is good, but the baby still doesn’t get the antibodies it needs. So getting it in pregnancy is the best practice.