vaccinations in pregnancy.ppt

7/27/2019 Vaccinations in Pregnancy.ppt

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Vaccinations

in PregnancyDr .Ashraf FoudaDamietta General Hospital

E-mail:[email protected]


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Adult immunization rates

have fallen short of national

goals, partly because ofmisconceptions about the

safety and benefits ofcurrent vaccines.


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The danger of these

misconceptions is magnifiedduring pregnancy, when:

1. Concerned physicians are hesitantto administer vaccines and

2. Patients are reluctant to acceptthem.


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The administration of

vaccines during pregnancyposes a number of concerns

about the risk of transmittinga virus to a developing fetus.

This risk is primarilytheoretic.


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The risk oftransmitting a virus to

a developing fetusis primarily theoretical


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Routine vaccines that

generally are safe duringpregnancy include:

1. Diphtheria,2. Tetanus,

3. Influenza, and

4. Hepatitis B


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Other vaccines,such as:

1.Meningococcal and

2.Rabies,may be considered.


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Vaccines that are contraindicated

include:,1. Measles, Mumps, and Rubella;

2. Varicella; and3. (BCG)bacille Calmette-Gurin.

(because of the theoretic risk

of fetal transmission)


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Theoretic risks of

vaccination must be

weighed against the

risks of the diseaseto mother and fetus.


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Inadvertent

administration of anyof these vaccinations,

isnot considered anindication for

termination of the

pregnancy


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Live-virus vaccinesare therefore

generallycontraindicated

in pregnant women.


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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.

Center for Disease Control and

Prevention (CDC)


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Physicians should reassuretheir patients that

no vaccines arecontraindicated during

breastfeeding

Immunization during

breastfeeding is safe


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Tetanus andDiphtheria


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Diphtheria is an infection

of the nasal, pharyngeal,laryngeal, or other mucous

membranes that can causeneuritis, myocarditis,

thrombocytopenia, and

ascending paralysis


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Tetanus infection cancause production of a

neurotoxin, leading totetanic muscle

contractions.


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Tetanustoxoidis routinely

recommendedfor susceptible

pregnant women.


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While no evidence exists to prove

that tetanus and diphtheria toxoids

are teratogenic,

waiting until the second trimester

of pregnancy to administer toxoidsis a reasonable precaution,

minimizing any concern about thetheoretic possibility of such

reactions.


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Previously vaccinatedpregnant women who have

not received a Tdvaccination within the past10 years should receive a

booster dose.

Tetanus and Diphtheria


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Pregnant women who

are not immunized oronly partially immunized

should complete theprimary series.

Tetanus and Diphtheria


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Influenza


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Fever, malaise, myalgia, andupper respiratory tract symptoms

or infections characterize influenzainfection.

Most severe complications are theresult of pneumonia secondary toinfluenza infection.

Influenza


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The influenza vaccine is

a killed virus preparationwith an annually

adjusted antigenicmakeup.

Influenza


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It should be

administered annuallybetween October and

December to high-riskpatients.

Influenza


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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


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Women in their second or thirdtrimesters have higher morbidity, frominfluenza infection.

Immunization should be avoided inmost patients during the first trimester

to avoid a coincidental associationwith spontaneous abortion, which iscommon in the first trimester.

Influenza


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Hepatitis A


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It is acquired via thefecal-oral route

by person-to-personcontact or ingestion ofcontaminated food or

water.

Hepatitis A


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Safety during pregnancy hasnot been determined.

Because hepatitis A vaccine isproduced from inactivated

virus, the risk to the developingfetus is expected to be low.

Hepatitis A


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Administration of immuneglobulin is strongly

recommended;which is considered safe during

pregnancy and is more than 85% effective in preventing acutehepatitis

Hepatitis A


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Hepatitis B


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Transmitted through:1.Contact with infected

blood,2.Sexual activity, and

3.Sharing of intravenousneedles.

Hepatitis B


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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


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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 acutelyinfected persons or persons with a

chronic carrier state.

Hepatitis B


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The hepatitis B vaccine containsviral surface antigen produced by

recombinant DNA technology.It is administered in three doses,at birth and at one and six monthsof age, and has minimal to no sideeffects.

Hepatitis B


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Because it containsnoninfectious hepatitis B

surface antigen particles andit cause no risk to the fetus,

neither pregnancy nor lactationis a contraindication tovaccination.

Hepatitis B


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Pneumococcal


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Streptococcus pneumoniaeis a gram-positive diplococci

that is a major cause of1. Pneumonia,

2. Meningitis, and3. Bacteremia.

Pneumococcal


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Risk factors for pneumococcalinfection in pregnant women include

1. Diabetes,2. Cardiovascular disease,

3. Immunodeficiency,4. Asthma.

Pneumococcal


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The current vaccine includespurified capsular

polysaccharidewomen at high risk should be

given this vaccination before,but not during, pregnancy.

Pneumococcal


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The safety of the vaccineduring pregnancy has not

been evaluated, although noadverse outcomes have beenreported among newborns

whose mothers wereinadvertently vaccinated.

Pneumococcal


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Polio


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Enterovirus with three different strainsthat cause disease.

Exposure may result in asymptomaticinfection as well as nonparalytic and

paralytic disease.Asymptomatic patients can transmit

the disease to susceptible persons

Polio


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The disease continues to be a

problem worldwide, but all recent

domestic polio cases have beencaused by the strains of virus

found in the oral polio vaccine(OPV).

Polio


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This situation has resulted in achange in the recommendation foruse of inactivated polio vaccine (IPV),

instead of OPV or a combination ofOPV-IPV for all routine vaccinations.

IPV is inactivated by formaldehyde,and its use has eliminated vaccine-associated polio infection.

Polio


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Although no adverse effectshave been documented with

OPV or IPV in pregnantwomen or their fetuses,both vaccines should be

avoided during pregnancy ona theoretic basis.

Polio


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The CDC states that IPV may beadministered in accordance with

the recommended schedules foradults if a pregnant woman is atincreased risk for infection and

requires immediate protectionagainst polio.

Polio


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Varicella


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Varicella vaccination is

contraindicated during

pregnancy because ofpotential adverse effects

on the fetus.


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The varicella-zoster viruscauses chickenpox and rarely

cause serious complications,(as encephalitis and

pneumonia).Up to 15 % of infected persons

have herpes zoster later in life

Varicella


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The varicella vaccine

contains live

attenuated varicella-zoster virus.

Varicella


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Women who are vaccinated shouldavoid becoming pregnant for one

month following each injection.The presence of pregnant household

members does not constitute acontraindication to vaccination ofothers within the house.

Varicella


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If a susceptible pregnantwoman is exposed to

varicella, however,administration of varicella-

zoster immune globulinshould be stronglyconsidered.

Varicella


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Theoretic risks to the fetus are verysmall, and exposure to the varicella

vaccine is not an indication fortermination of pregnancy.

Data from more than 300 deliveries

indicate no birth defects compatiblewith congenital varicella syndrome.

Varicella


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Meningococcal

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In the USA, meningococcal disease isthe leading cause of bacterial

meningitis in children ages twothrough 18 years.

Meningococcal vaccine contains thepurified polysaccharide of four

serogroups of Neisseria meningitidis

Meningococcal


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Routine vaccination is recommendedfor high-risk groups, including

1. Military recruits,2. Patients with terminal complement

component deficiencies, and3. Persons with anatomic or functional

asplenia

Meningococcal


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Vaccination also may benefit travelers toareas in which N. meningitidis is endemic

or epidemic, such as sub-Saharan Africa.Studies have shown that the

meningococcal vaccine is safe andefficacious when given to pregnant

women

Meningococcal


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Measles,

Mumps,

andRubella


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It is caused by the measlesvirus, typically presents with:

1. Fever,2. Coryza,

3. Generally ill appearance, and4. Confluent, erythematous,

maculopapular rash

Measles

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Mortality occurs in1-2 per 1,000 cases,often secondary to

pneumonia orencephalitis.

Measles


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Measles, mumps, and

rubella vaccineshould not be given to

pregnant women,because of potential

adverse effects on thefetus.

M


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Mumps results from infection withthe mumps virus and can lead to

parotitis, meningoencephalitis, andorchitis.

Neurologic complications, such asdeafness, can also occur as aresult of mumps infection.

Mumps


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Rubella

Rubella, or German

measles, is caused

by the rubella virus.


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Women should be counseled to avoidbecoming pregnant within four weeks

of vaccination by MMR.Pregnancy has been considered a

contraindication to vaccination with

the rubella vaccine because ofpotential adverse effects on the fetus.

Measles, Mumps, and Rubella

Measles Mumps and Rubella


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For women who received rubella vaccine within

three months of conception.

Pregnancy outcomes in 683 vaccine recipients

showed no evidence that the rubella vaccinecaused any fetal abnormalities or congenital rubella

syndrome.

However, rubella-specific IgM has been detected incord blood, suggesting possible subclinical

infection.


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Because of the theoretic risk,guidelines state that precautions

should be used to prevent rubellavaccine administration duringpregnancy, but pregnancy testingbefore vaccination is notconsidered to be necessary.



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Other Vaccinations

V i ti t i ll t


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Vaccinations typically notadministered on a routine basisby family physicians and othervaccines of interest include:

anthrax, smallpox, rabies,Japanese encephalitis, yellow

fever, BCG, typhoid, cholera,and plague.


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ANTHRAX


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Anthrax is caused by thespore-forming bacterium

Bacillus anthracis,occurring inhumans in three forms:

1. Cutaneous,2. Inhalational, and

3. Gastrointestinal

ANTHRAX

ANTHRAX


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The potential use of anthrax inacts ofbioterrorism has long

been a concern because of its:1. Stability,

2. High mortality, and

3. High potential for respiratorytransmission.

ANTHRAX

ANTHRAX


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The anthrax vaccine isprepared from a bacteria-

free culture containing thethree major toxin

components produced bythe bacteria

ANTHRAX

ANTHRAX


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The recommended immunizationschedule consists of:

1. Three injections given at two-week intervals,

followed by another2. Three doses at six-month

intervals.

ANTHRAX

ANTHRAX


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No studies have addressed thesafety of the anthrax vaccine

during pregnancy.As with other non live- virus

vaccines, anthrax vaccine does notcarry theoretic risks of fetalinfection.

ANTHRAX

ANTHRAX


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Vaccination should beconsidered on a case-by-casebasis and administered onlywhen the potential benefits

outweigh the potential risksto the mother and fetus.

ANTHRAX


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SMALLPOX


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Smallpox is an

orthopoxvirus, was certified

as eradicated in 1980,

and

no longer occurs naturally.

SMALLPOX

SMALLPOX


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Prodromal symptoms include ahigh fever and oral lesions thatulcerate, followed by a macularrash.

The rash becomes raised, then

umbilicated and pustular,particularly when on the face and

extremities

SMALLPOX

SMALLPOX


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Recent world events havebrought to light the threat

of terrorists who mayrelease smallpox, and have

prompted an evaluation ofvaccination policies

SMALLPOX

SMALLPOX


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Vaccinia vaccine should

not be administered topregnant women for

routine nonemergencyindications.

SMALLPOX

SMALLPOX


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Smallpox infection amongpregnant women has

been reported to result ina more severe infection

than among nonpregnantwomen.

SMALLPOX

SMALLPOX


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The vaccine has not been shownto be teratogenic or to causecongenital malformations, but the

virus has been reported to causefetal infection on rare occasion,

with subsequent risk ofskin lesions, preterm delivery,

stillbirth, or infant death.

SMALLPOX

SMALLPOX


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Women should thereforeactively avoid becomingpregnant for at least four

weeks after vaccination and

until the scab has completelyhealed and fallen off.

SMALLPOX

SMALLPOX


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Vaccination should also be avoidedfor household or close contacts of

women who are pregnant.Inadvertent vaccination duringpregnancy, however, should notbe considered a reason toterminate the pregnancy

SMALLPOX

SMALLPOX


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The safety of breast milk aftermaternal vaccination has not beenstudied, so women who are

breastfeeding should not receivethe vaccine.

Household contacts ofbreastfeeding infants theoretically

can be immunized

SMALLPOX


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RABIES

RABIES


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Rabies is a viral infectiontransmitted most commonly by

the saliva of infected animals.Nonspecific prodromal symptoms

progress to encephalitis markedby confusion, hallucinations.

RABIES

RABIES


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Dysregulation of the autonomicnervous system and involvement of

the brainstem and cranial nerves leadto the classic "foaming at the mouth"appearance.

Three forms of inactivated rabiesvaccines are available, all considered

equally safe and efficacious

RABIES

RABIES


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Passive immunization is achieved

through administration of humanrabies immune globulin (HRIG).

Indications for pre-exposureimmunization depend on thelikelihood of exposure.

It may be considered in animalworkers and travelers to enzootic

areas who anticipate animal exposure

RABIES


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With any animal bites or

wild animals, the animalshould be euthanized,

and the brain tested forinfection.

RABIES

RABIES


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Bites from normally actingdogs, cats warrant a 10-day

observation period,with prophylaxis and

euthanization of the animaldeferred.

RABIES

RABIES


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In patients who have not been immunizedpreviously, 20 IU per kg of HRIG is givenat the wound site for high-risk bites or iftesting is positive.

Patients with previous vaccinations do notneed HRIG but do require revaccinationon a modified schedule.

There have been no identified associationsbetween rabies vaccination and fetalabnormalities

S


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JAPANESE ENCEPHALITIS



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Japanese encephalitis (JE) is theleading cause of viralencephalitis in Asian countries,

With one quarter of caseshaving a fatal outcome, and

Residual neuropsychiatricsequelae occurring in up to onehalf of survivors.



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Most human infections

occur in rural areas, where

flooded rice fields support

large populations of the

Culex mosquitoes that

transmit the virus




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Travelers to rural parts of Asia have ahighly variable risk of acquiring JE

infection, estimated at approximately1 in 5,000 per month.

In the case of short-term travel to

urban areas, however, risks ofacquiring JE infection are less thanone per million.




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@Vaccination is

recommended onlyfor travelers with

a significant risk ofexposure.




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The vaccine is an inactivated virusvaccine that produces a 99% rate

of seroconversion after threedoses.

No specific data are availableregarding JE vaccine safety inpregnancy.




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Since JE infection during thefirst and second trimesters has

been associated withintrauterine infection andmiscarriage,

the vaccine is notrecommended during this time




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Infections during thethird trimester have notbeen associated withadverse outcomes in

newborns.




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Vaccination should beconsidered before conception

in a woman who will betraveling to high-risk areas

while pregnant, in conjunctionwith optimized mosquito-bite

precautions.



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YELLOW FEVER

YELLOW FEVER


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Yellow fever is a viral hemorrhagicfever syndrome spread by

mosquitoes in parts of SouthAmerica and Africa.

The yellow fever vaccine is a live,attenuated virus grown in chickembryos.

YELLOW FEVER

YELLOW FEVER


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It is indicated for use in

laboratory workersinvolved with the virusand in persons planning totravel to endemic areas.

YELLOW FEVER

YELLOW FEVER


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No specific evidence is available todemonstrate the safety of yellowfever immunization during

pregnancy.Since theoretic concerns of fetal

infection exist, however,vaccination is generally notrecommended during pregnancy.

YELLOW FEVER


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When travel cannot bepostponed and mosquito

exposure is likely,

yellow fever vaccinationmay be considered.

YELLOW FEVER


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BCG VACCINE

BCG VACCINE


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Mycobacterium tuberculosiscauses more than 8 millionnew cases of tuberculosis

(TB) annually,the majority of them indeveloping countries.

BCG VACCINE

BCG VACCINE


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BCG(bacille Calmette-Gurin)

vaccine is a live vaccinederived from a strain ofMycobacterium bovis.

BCG VACCINE


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It is likely that the BCG vaccinehas been given to thousands of

pregnant women in othercountries.

While no harmful fetal sideeffects have been identified todate.

BCG VACCINE


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Use of the BCG

vaccine isnot recommendedduring pregnancy.

BCG VACCINE


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TYPHOID

TYPHOID


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Most cases of typhoid fever indeveloped countries occur in

travelers who recently havereturned from high-risk areas,

such as South America, India,and western Africa

TYPHOID

TYPHOID


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Transmission ofSalmonella typhi

is significantly increased withtravel during

local epidemics andingestion of food from streetvendors.

TYPHOID

TYPHOID


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Primary prevention consists of:

1. Hand washing,

2. Drinking only safe water,

3. Peeling all fruits and

vegetables, and4. Eating well-cooked foods.

TYPHOID

TYPHOID


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The two types of typhoid vaccination inuse today are a live attenuated oral

vaccine and a parenteral polysaccharidevaccine.

Both forms require that immunization becompleted at least two weeks before

exposure.

TYPHOID

TYPHOID


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Its use is contraindicated in:1. Infants,

2. Immunocompromised persons, and3. Those with abnormal gastrointestinal

function, as well as4. Pregnant women.

TYPHOID


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Neither form of

typhoid vaccine isofficially

recommended duringpregnancy.

TYPHOID


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CHOLERA

CHOLERA


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Cholera is an acute diarrheal diseaseendemic to Africa, Asia, and LatinAmerica.

It is caused by a toxin from Vibriocholerabacteria, which live in, and

are transmitted by, the fecal-oralroute from contaminated watersources.

CHOLERA


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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, andlonger lasting than the parenteral vaccine.

These may be considered for use inpopulations at immediate risk of a choleraepidemic or for travelers to areas of high

endemicity

CHOLERA


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No specific information exists onthe safety of parenteral cholera

vaccination during pregnancy.Because cholera during pregnancyis a serious illness, exposureshould be minimized duringpregnancy whenever possible.


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PLAGUE

PLAGUE


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Plague, a disease caused by Yersiniapestis, is naturally hosted by rodents andtheir fleas.

It occurs more commonly in semi-ruralareas of Africa, Asia, and South America.

The plague vaccine is no longercommercially available in the UnitedStates.

PLAGUE

PLAGUE


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It was recommended only for use intravelers to endemic areas who had ahigh risk of exposure to wild rodents and

fleas. Its efficacy was not well studied.

All persons with definite exposure shouldreceive a seven-day course of appropriateantibiotics (often doxycycline, or

trimethoprim-sulfamethoxazole)

PLAGUE

PLAGUE


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The effects of plague vaccine on thedeveloping fetus are not known.

Pregnant women should avoid high-risk

situations and use insecticides and otherprotective measures.

Prophylactic antibiotics that are safeduring pregnancy may be considered inwomen with a substantial risk of infection.

PLAGUE

Preconceptional


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Preconceptional

immunization of pregnantwomen to prevent disease

in the offspring ispreferred to vaccination

of pregnant women.

The benefits of


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The benefits of

immunization to thepregnant woman and her

neonate usuallyoutweigh the theoretic

risks of adverse effects.

The theoretic risks of


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The theoretic risks of

the vaccination ofpregnant women withkilled virus vaccines

have not beenidentified.

f


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Vaccination of womenduring the postpartum

period, especially forrubella and varicella,

should be encouraged.

Women susceptible to


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Women susceptible to

rubella should bevaccinated with

measles

mumps

rubellaon postpartum discharge

from the hospital.

Generally,


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y,

live-virus vaccinesare contraindicated for

pregnant women becauseof the theoretical risk of

transmission of the vaccinevirus to the foetus.

Whether live or inactivated


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vaccines are used,vaccination of pregnant

women should be considered

on the basis ofthe risk of the vaccination vs.

the benefits of protection in aparticular circumstance.


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vaccinations in pregnancy.ppt

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