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Pertussis in Pregnancy

6/1/2016 - Sarah Shaffer, DO

Mentor: Thomas M. Gellhaus, MD

Editor:  Christopher M. Zahn, MD

Approved:  3/1/16

Pertussis, also known as whooping cough, is a highly contagious respiratory disease caused by the bacterium Bordatella pertussis.  Infection causes paroxysms of coughing, which can lead to dyspnea, hypoxia and apneic spells in infants.  Half of all affected infants require hospital care, one in four will get pneumonia, and mortality is 1%.  Although adults suffer less, coughing spells may be severe enough to fracture ribs.  It is uncertain if pertussis infection in a pregnant adult is associated with increased morbidity or mortality.

The majority of pertussis infections in infants are contracted from family members and caregivers.  Pertussis occurring up to three months of age accounts for the majority of neonatal morbidity and mortality related to this disease.  Infants do not begin the pertussis vaccine series until two months of age when a diphtheria, tetanus and acellular pertussis (DTaP) vaccine is recommended.  This period of immunologic vulnerability for the infant is best addressed by vaccinating those close to and caring for the infant.  Tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) stimulates development of maternal antipertussis antibodies that then pass through the placenta, resulting in passive immunization of the fetus.  However, waning of immunity has been demonstrated within one year of receipt of Tdap vaccine during pregnancy. 

The CDC’s Advisory Council on Immunization Practices (ACIP) updated their recommendations in 2013 focusing on the infant’s lack of endogenous protective antibody in the first 2-3 months of life.  This revision advocates Tdap vaccination during every pregnancy, irrespective of the patient’s history of immunization with Tdap or other related vaccines.  To maximize maternal antibody response, passive antibody transfer and, therefore, antibody levels in the neonate, optimal timing of Tdap administration is between 27 and 36 weeks of gestation.  However, Tdap vaccination at any time during the pregnancy is safe and suggested.  If Tdap is not administered during the pregnancy, vaccination should occur immediately post-partum; it is safe to administer Tdap to breastfeeding women.  Furthermore, other family members and care-givers should be vaccinated with Tdap at least two weeks prior to contact with the neonate.

Reproductive-age women who live or work in areas with pertussis epidemics should be immunized per recommendations for non-pregnant adults; vaccination of pregnant women in epidemic areas is encouraged outside the 27 to 36-week window.  Women should not be re-vaccinated with Tdap if a vaccine was administered during the first or second trimester.  If a tetanus and diphtheria (Td) booster is required by a pregnant woman as part of a wound management protocol, it should be replaced with a Tdap vaccine, irrespective of gestational age.  Pregnant woman who have not been vaccinated for tetanus previously can and should start the Td three-vaccine series (0 weeks, 4 weeks and 6-12 months); one dose of Td should be replaced with Tdap, preferably timed near or in the 27 to 36-week window.

Further Reading:

Updated Recommendations for Use of Tetanus Toxoid, Reduced Diptheria Toxoid, and Acellular Pertussis Vaccine (Tdap) in Pregnant Women, CDC ACIP, MMWR, Feb 2013, Vol 62, #7.

Update on Immunization and Pregnancy: Tetanus, Diptheria, and Pertussis Vaccination, ACOG Committee Opinion #566, reaffirmed 2015.

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