Protocol and safety notice: Vaccine availability, schedules and prophylaxis products change. Use the current Uganda Ministry of Health/UNEPI schedule and facility formulary, check the exact product label and consult senior staff for travel, outbreak, post-exposure or high-risk decisions. A serious vaccine-preventable infection can be more dangerous to mother and fetus than the theoretical risk of an indicated non-live vaccine.
This post expands the supplied 58-slide vaccination-in-pregnancy presentation into a practical Uganda-focused guide to active immunisation, passive immunisation and antenatal prophylaxis. It separates vaccines that are routinely useful, vaccines used only after a risk–benefit assessment, live vaccines generally deferred, and the medicines/interventions that prevent anaemia, malaria, neural-tube defects, RhD disease, HIV transmission and pre-eclampsia.
Learning objectives
- Explain active versus passive immunisation and how maternal antibodies protect the newborn.
- Choose vaccines by platform, gestational age, exposure risk, outbreak status and national policy.
- State usual dose principles, contraindications, precautions, adverse effects and post-exposure actions.
- Construct a complete antenatal prophylaxis plan and teach the woman what to expect after each intervention.
1. First principles
Active and passive immunisation
- Active immunisation: a vaccine stimulates the mother’s immune system to produce protection that lasts beyond pregnancy. IgG crosses the placenta, especially in late pregnancy, and protects the newborn for the first vulnerable weeks.
- Passive immunisation: an immunoglobulin supplies ready-made antibodies for rapid, temporary protection after a high-risk exposure (for example rabies, hepatitis B, varicella or tetanus). It does not replace vaccination.
- Inactivated, toxoid, subunit and conjugate vaccines cannot replicate and are generally suitable when indicated.
- Live attenuated vaccines are usually avoided during pregnancy because of theoretical fetal infection risk; inadvertent administration is not an indication for termination—provide counselling and specialist follow-up.
Pre-vaccination assessment
- Confirm pregnancy, gestational age, prior vaccine record and previous adverse reactions.
- Ask about immunocompromise, HIV, steroid/chemotherapy use, splenectomy, allergies (especially anaphylaxis), fever/acute illness and recent immunoglobulin or blood products.
- Assess disease exposure: household contacts, occupation, travel, animal bites, outbreak, sexual/needle exposure and local epidemiology.
- Explain benefits, common reactions, rare serious reactions, alternatives and the plan if the vaccine is unavailable.
- Obtain consent, administer using aseptic technique, observe briefly and document product, batch, dose, route, site, date and next due dose.
2. Vaccines generally used during pregnancy
| Vaccine | When/why | Dose and practical notes |
|---|---|---|
| Tetanus–diphtheria (Td/TT) | Routine maternal and neonatal tetanus prevention; give at the first ANC contact if protection is incomplete and continue the national series. | Usually 0.5 mL IM per dose. Uganda/UNEPI schedule depends on documented previous doses; a common five-dose lifetime series is Td1 at first contact, Td2 ≥4 weeks later, Td3 ≥6 months later, Td4 ≥1 year after Td3 and Td5 ≥1 year after Td4. Do not restart a documented series—verify the current national schedule. |
| Inactivated influenza | Protects a pregnant woman, who has increased risk of severe influenza, and transfers antibody to the infant. Use seasonal vaccine when available and recommended locally. | Usually one 0.5 mL IM dose each season; safe in any trimester when indicated. Do not use live intranasal influenza vaccine in pregnancy. |
| COVID-19 vaccine | Offer according to current Uganda policy, circulating variants, risk and product availability; pregnancy increases risk from severe respiratory disease. | Product-specific dose/interval. Vaccination can usually be co-administered with other non-live vaccines; check current national guidance. |
| Hepatitis B | Pregnancy is not a contraindication. Vaccinate an unprotected woman with risk of infection (household/sexual contact, health work, injection exposure or high prevalence) and test HBsAg for eMTCT. | Common adult schedule 20 micrograms IM at 0, 1 and 6 months (product-dependent). If exposed, add HBIG promptly plus vaccine; newborn needs timely birth-dose vaccine and HBIG when indicated. |
| Rabies vaccine | Post-exposure prophylaxis (PEP) is life-saving after a suspected exposure; pregnancy is not a reason to withhold it. | Immediately wash/flush wound with soap and water. Infiltrate human rabies immunoglobulin (commonly 20 IU/kg) into/around the wound when indicated, then give cell-culture vaccine on national days (often 0, 3, 7, 14 and 28 for immunocompromised patients or per protocol). Never delay PEP for pregnancy testing. |
3. Vaccines used only after individual risk–benefit assessment
| Vaccine | Possible indication | Key caution |
|---|---|---|
| Hepatitis A | Travel to endemic areas, outbreak, chronic liver disease or high exposure risk. | Inactivated vaccine; use when benefit outweighs limited pregnancy data. |
| Meningococcal (preferably conjugate according to policy) | Outbreak, close contact, asplenia or travel to a high-risk area. | Coordinate with public-health/travel clinic. |
| Pneumococcal | High-risk conditions such as sickle-cell disease, asplenia, HIV or chronic heart/lung/renal disease. | Not a routine vaccine for every pregnancy; specialist/public-health advice. |
| Inactivated typhoid | Essential travel or outbreak risk when food/water precautions cannot adequately reduce exposure. | Avoid live oral Ty21a; discuss benefit and local product. |
| Yellow fever | Travel to a yellow-fever risk area or official requirement. | Live vaccine: defer if travel can be avoided; if exposure risk is high, specialist risk–benefit decision is safer than leaving an unprotected woman. |
| Japanese encephalitis | Long stay/travel in an endemic area with substantial mosquito exposure. | Use only after specialist travel assessment; mosquito avoidance remains essential. |
| Cholera | Outbreak or exceptional high-risk exposure. | Use the current outbreak/public-health protocol; safe water and sanitation are central. |
| IPV (inactivated polio) | Outbreak or high-risk travel. | Use only when indicated; avoid oral live polio vaccine in pregnancy where possible. |
| RSV maternal vaccine | Where licensed and included in the national programme, may be offered during the recommended late-gestation window to protect the newborn. | Availability and schedule are evolving; follow current Uganda/WHO policy and product label. |
4. Live vaccines generally deferred during pregnancy
- Measles–mumps–rubella (MMR), varicella and combined MMRV.
- Live attenuated intranasal influenza.
- BCG and oral live polio vaccine, unless a public-health emergency leaves no safer alternative.
- Live typhoid (Ty21a), live yellow fever and other live travel vaccines unless an expert determines the exposure risk is greater than the theoretical vaccine risk.
- HPV vaccine is usually deferred until after pregnancy; if given inadvertently, do not repeat the dose during pregnancy and complete the series postpartum.
Inadvertent live-vaccine exposure: document vaccine/date/gestation, reassure that inadvertent exposure alone is not an indication for termination, report according to pharmacovigilance policy and arrange antenatal follow-up. Do not perform routine pregnancy testing before every vaccine unless clinically indicated.
5. Passive immunisation and post-exposure prophylaxis
| Exposure | Passive product/action | Key points |
|---|---|---|
| Rabies | Human rabies immunoglobulin plus vaccine. | Wash wound immediately; infiltrate immunoglobulin into wound, give the complete cell-culture vaccine series. Pregnancy is not a contraindication. |
| Hepatitis B | HBIG plus HepB vaccine after significant exposure. | Give as soon as possible according to national timing; test and follow the mother, and ensure newborn birth-dose prophylaxis for an HBsAg-positive mother. |
| Varicella | Varicella-zoster immunoglobulin for a susceptible pregnant woman after significant exposure when available. | Contact public health urgently; do not administer live varicella vaccine during pregnancy. |
| Tetanus-prone wound | Tetanus toxoid/Td vaccination and tetanus immunoglobulin when indicated. | Clean/debride wound, check previous doses and follow the wound-management guideline. |
| RhD alloimmunisation | Anti-D immunoglobulin (not a vaccine). | For an RhD-negative, non-sensitised woman after sensitising events and/or routine late-pregnancy prophylaxis; use current local dose/timing and antibody testing. |
6. Antenatal prophylaxis beyond vaccines
6.1 Iron and folic acid
- Routine prevention generally uses 30–60 mg elemental iron plus folic acid 400 micrograms (0.4 mg) daily according to Uganda products; continue through pregnancy and postpartum as directed.
- High-risk folate (commonly 5 mg daily before conception through 12 weeks) is clinician-prescribed for a previous neural-tube defect, malabsorption, sickle cell disease or folate-interfering medicines.
- Check adherence, constipation, nausea, bleeding, malaria and haemoglobinopathy. Severe/symptomatic anaemia needs therapeutic assessment, not routine prophylaxis alone.
6.2 Malaria prevention
- IPTp-SP: in endemic Uganda, start after the first trimester/around 13 weeks when eligible and give under observation at least one month apart; many programmes target at least three doses. Usual dose is three tablets, each sulfadoxine 500 mg/pyrimethamine 25 mg (total 1,500/75 mg). Avoid in serious sulfonamide allergy and do not co-administer with cotrimoxazole; follow current national policy for HIV.
- LLIN: sleep under a long-lasting insecticidal net every night, repair/replace it and reduce mosquito exposure.
- IPTp does not treat fever. Test and promptly treat confirmed malaria with a gestation-appropriate regimen.
6.3 Deworming
After the first trimester, Uganda programmes may provide mebendazole (often 500 mg once or the approved local equivalent) when indicated. Check the current schedule, anaemia, nutrition and contraindications; combine with sanitation, footwear and safe food/water.
6.4 Calcium and pre-eclampsia prevention
- Where dietary calcium intake is low, WHO commonly recommends 1.5–2.0 g elemental calcium daily in divided doses; follow Uganda protocol and separate from iron by at least two hours.
- For selected high-risk women, low-dose aspirin 75–150 mg nightly from 12–16 weeks to about 36 weeks may be prescribed. Check bleeding risk, allergy, ulcer disease and local policy; it is not universal self-medication.
6.5 HIV and STI prevention
- Test with consent, start/continue lifelong combination ART promptly, monitor viral load and adherence, and plan delivery/newborn prophylaxis under Uganda eMTCT guidance.
- Use condoms when indicated, test/treat partner(s), screen for syphilis and hepatitis B, and counsel on avoiding alcohol, tobacco and injectable drugs.
7. Vaccine administration and safety
Before injection
- Check the vaccine name, expiry, cold chain, dose, route, site, contraindication, consent and patient identity.
- Ask specifically about previous anaphylaxis to the same vaccine or component; mild fever, breastfeeding, antibiotic use or a family history of vaccine reactions are usually not contraindications.
- Do not delay a needed vaccine solely because the woman is in the first trimester; weigh disease risk and national recommendations.
After injection
- Observe according to facility policy (often 15 minutes), provide a phone/return plan and explain expected local pain, fatigue or low fever.
- For fever or discomfort, hydration/rest and clinician-approved paracetamol may be used; avoid self-starting NSAIDs.
- Emergency signs include wheeze, facial/throat swelling, collapse, widespread urticaria or persistent vomiting—treat as anaphylaxis immediately with IM adrenaline according to the emergency protocol, airway/oxygen and urgent transfer.
8. Co-administration, spacing and missed doses
- Most non-live vaccines can be given at the same visit at different sites; use the current product guidance.
- Do not restart a vaccine series because a dose was late—continue using the minimum interval unless the national programme says otherwise.
- Iron, calcium, antacids and some medicines interact by reducing absorption; schedule them separately.
- Record every dose on the ANC card and immunisation register so future clinicians do not repeat or omit protection.
9. Pre-conception and postpartum catch-up
- Before pregnancy, update MMR, varicella, HPV and other indicated vaccines; avoid conception for the interval specified by the product/national guideline after a live vaccine.
- If a live vaccine was missed, give it postpartum before discharge or at follow-up, unless contraindicated. Breastfeeding is not a reason to defer most vaccines.
- Review household contacts: vaccinating close contacts against influenza, pertussis, COVID-19 and varicella can reduce newborn exposure.
10. Communication and myth correction
| Concern | Evidence-based response |
|---|---|
| “Vaccines cause infertility.” | Recommended non-live vaccines do not cause infertility; preventing severe infection protects future reproductive health. |
| “No vaccine is safe in the first trimester.” | Live vaccines are generally deferred, but indicated inactivated vaccines and emergency PEP can be given when benefits outweigh risk. Do not miss life-saving rabies or tetanus care. |
| “A fever after vaccination means danger to the baby.” | Mild short-lived fever or injection pain is common; severe allergic symptoms, persistent high fever or collapse need urgent review. |
| “One Td dose protects for life.” | Protection depends on previous doses and intervals; complete the national series and document it. |
| “Herbal prophylaxis is safer.” | Unregulated products may contain toxic or teratogenic substances and interact with ART, antimalarials or iron. Ask the health worker before use. |
11. Practical antenatal checklist
- Check vaccine/prophylaxis history and gestational age.
- Screen for disease risk, allergies, immunocompromise, acute illness and exposure.
- Offer Td/TT, influenza, COVID-19, HepB or other indicated vaccines according to Uganda policy.
- Start/continue iron–folate; assess need for calcium, IPTp-SP, deworming, LLIN, aspirin and anti-D.
- Explain benefits, common side effects, danger signs and next dose date.
- Administer safely, observe, document product/batch/dose/site and update the ANC card.
- Arrange follow-up and referral for abnormal Hb, HIV/syphilis/hepatitis, fever, severe allergy or high-risk exposure.
Quick self-test
- Which vaccine classes are generally deferred during pregnancy and why?
- State the usual Td/TT documentation principle when previous doses are uncertain.
- What are the key actions after a suspected rabies exposure in pregnancy?
- What is the usual IPTp-SP tablet dose and when does it begin?
- Name four non-vaccine antenatal prophylaxis interventions.
- What symptoms after vaccination suggest anaphylaxis?
Answers
- Live attenuated vaccines such as MMR, varicella, live nasal influenza and oral polio because of theoretical fetal infection risk; use specialist advice for high-risk travel/outbreaks.
- Verify records and continue the national series without restarting documented doses; record product, dose, date and next due dose.
- Immediate wound washing, infiltrated rabies immunoglobulin when indicated, complete cell-culture vaccine schedule and urgent public-health/clinical follow-up—do not withhold because of pregnancy.
- Three SP tablets (500/25 mg each) once under observation, starting after the first trimester/around 13 weeks in endemic areas and repeated at least monthly as eligible; follow Uganda policy.
- Iron–folate, calcium, LLIN/IPTp, deworming, aspirin for selected high risk, anti-D for RhD-negative women and HIV eMTCT.
- Wheeze, throat/facial swelling, collapse, widespread hives, hypotension or rapidly progressive vomiting/breathing difficulty.
Further study and source integration
- Supplied Slideshare: Vaccination in pregnancy (58-slide presentation)
- Safe Mama Uganda: Antenatal care and preventive interventions
- WHO: Vaccination before and during pregnancy
- CDC: Guidelines for vaccinating pregnant women
Take-home message: The safest plan is not “vaccinate everything” or “avoid everything.” Assess disease risk, vaccine platform, gestation, exposure and national policy; give indicated protection promptly, defer live vaccines when possible, and document every dose and prophylactic intervention.
