Review Question - QID 107199

This patient with an up-to-date vaccination history who wants to become pregnant in the next month should be tested for rubella and varicella titers only - vaccination is not recommended unless these titers show insufficient immunity. Patients should wait one month after vaccination with a live-attenuated vaccine (MMR, varicella, etc) before becoming pregnant.

There is an extremely small, theoretical risk of conversion of a live-attenuated vaccine that could lead to infection of the patient and her fetus. Because of this, the CDC recommends that pregnant women not be administered a live-attenuated vaccine such as MMR, varicella, or live-attenuated influenza. If a woman receives a live-attenuated vaccine, she should be counseled to avoid becoming pregnant for one month after the vaccination. If a patient without demonstrated immunity by titer is already pregnant or wishes to become pregnant in the next month, then she should be counseled on the risks of congenital rubella syndrome and the importance of being vaccinated as soon as they are no longer pregnant. If a pregnant patient is accidentally vaccinated or if a woman becomes pregnant one month after receiving a live-attenuated vaccine, she should be counseled on the theoretical risk to her fetus, but no changes to her prenatal care are necessary.

Zakrzewski et al. discuss rubella infection and vaccinations in pregnancy. Rubella infection in pregnancy is highly likely to lead to miscarriage, stillbirth, or congenital rubella syndrome, which manifests with cataracts, deafness, heart disease, and intellectual disability. As such, it is imperative to determine the patient's immune status in the pre-pregnancy stage so that vaccination can be provided before becoming pregnant.

Badilla et al. studied the effects of rubella vaccination in over 1000 Costa Rican patients who were unknowingly pregnant. They found no association of adverse pregnancy outcomes (including miscarriage, stillbirth, low birth weight, prematurity, or symptoms/signs of congenital rubella syndrome) with receipt of the rubella vaccine while pregnant.

Illustration A is a chart showing what vaccinations are appropriate at what stages of pregnancy.

Incorrect Answers:
Answer 1: Folic acid supplementation is recommended one month before becoming pregnant as well as throughout pregnancy.
Answer 2: Inactivated influenza vaccination is recommended for all women who will be pregnant during any part of the influenza season.
Answer 3: Rubella titer should be obtained to ascertain the patient's immunity status.
Answer 5: Varicella titer should be obtained to ascertain the patient's immunity status; although administration of the live vaccine presents a theoretical risk, it is important to discuss options with the patient.