OBGYN Doctor Discusses COVID-19 Vaccine in Pregnancy and Breastfeeding
Everything you need to know about the COVID-19 vaccine in pregnancy and breastfeeding in a comprehensive and simplified review.
I get lots of questions about the COVID-19 vaccine in pregnant and lactating women. I thought I would break it down for you in a simple and systematic fashion.
Disclaimer: while I am a doctor, I am not your doctor. If you have any specific questions, talk to your healthcare provider. This does not apply to all pregnant and lactating people, but to the majority. If you have a co-morbidity or any illness, talk to your healthcare provider.
Also, this is an evolving topic. This is up to date as of 1/4/2020. I cannot guarantee that the information will be up to date when you read this. I will try to update this document as new information comes in.
True or False: The COVID-19 vaccine trials did not include pregnant and lactating women.
True.
Unfortunately, most vaccine and medication trials do not include pregnant and lactating women.
This dates back to many years ago, when the Institutional Review Board (commonly known as IRB) was formed. The role of the IRB was to make sure that scientific research is performed in an ethical way. Because prior to the IRB, many unethical practices were conducted.
Pregnant women are considered a vulnerable population. Other vulnerable populations include: children, individuals who are economically disadvantaged, residents of a facility (treatment centers), and individuals who are incarcerated (prisoners). A vulnerable population is a group of people thought to require more protection than normal against the potential risks of participating in research. Individuals in vulnerable populations may have a higher risk of negative outcomes as a result of participating in a research study, they may have a reduced capacity or ability to give consent, or they may (for other reasons) have special legal protections.
Unfortunately, the pendulum has swung so far the other way that we began excluding certain vulnerable populations, such as pregnant women and children, from studies of potentially life-saving medications and vaccinations.
We cannot go back in time and change this.
True or False: Because pregnant women were not included in the trials, they should not be offered the vaccine.
False.
Most medical societies caring for pregnant and lactating women unanimously agrees that pregnant and lactating women should be offered the COVID-19 vaccine. I will link resources below.
True or False: The U.S. is recommending the COVID-19 vaccine to pregnant and lactating women.
True.
The American College of Obstetricians and Gynecologists (ACOG), the Society of Maternal Fetal Medicine (SMFM) and the CDC have put out statements urging pregnant and lactating women to not be excluded from the option of vaccination against COVID-19. See references below.
True or False: The UK is not recommending the COVID-19 vaccine to pregnant and lactating women.
False (but was true).
This is based on the recommendations by the British OBGYN society, the Royal College of Obstetricians and Gynecologists (RCOG). Since the vaccine was not studied on pregnant and lactating people, they are essentially excluded most from having the option to receive the vaccine.
This is the latest from RCOG (December 30, 2020):
"If a pregnant woman meets the definition of being clinically extremely vulnerable, then she should discuss the options of COVID-19 vaccination with her obstetrician and/or doctor. This is because their underlying condition may put them at very high risk of experiencing serious complications of COVID-19..."
(this is different from U.S. recommendations that acknowledge that pregnant women are high risk, even without co-morbidities)
"Additionally, pregnant women who are frontline health or social care workers, including carers in a residential home, can also discuss the option of vaccination. This is because the risk of exposure to COVID-19 may be higher, even if they have a lower risk of experiencing complications if they are otherwise well."
I am glad for this update in recommendations (it was complete exclusion of all pregnant and lactating women just a couple weeks prior). I am hoping they revise their recommendations to include all pregnant and lactating women once we get more information, which will hopefully coincide to when it is their turn to receive the vaccine.
True or False: Pregnant women are at increased risk of having side-effects from the vaccine.
False.
I don't actually know the answer to this, but as a doctor and scientist, I know that we don't always have answers, but often extrapolate answers from existing evidence.
Here is what we know:
Pregnant women do just fine after vaccines, including the 2 that we routinely recommend in pregnant (influenza vaccine and Tdap) and are not at increased risk of side effects.
Certain vaccines contain a piece of a live virus, these vaccines are called live-attenuated vaccines. These may cause mild symptoms in healthy adults (a mild form of the illness). These are contraindicated in pregnancy. Why? Because pregnant women do WORSE when they get pretty much any infection. An example is the chickenpox vaccine. These are theoretical concerns: if you accidentally receive those kind of vaccines and didn't know you were pregnant, it is OK! Studies show no adverse events in these cases.
COVID-19 vaccine does not contain a live virus. It is an mRNA virus. It contains a piece of RNA. When injected into the body, we form antibodies to this mRNA. When we get a COVID-19 infection, our body remembers prior exposure and antibody formation ramps up and attacks the surface of the SARS-CoV-2 virus before it can cause much damage.
True or False: The vaccine can cross the placenta and go to the fetus.
True (probably).
Most things we consume, including medications, foods, lotions, etc. have the potential to cross the placenta and get into the fetal circulation, as well as in breastmilk. Most medications, vaccines, herbal supplements cross over in tiny amounts. Like 1% of what you take can go to the baby. Some things we want to cross the placenta, such as folic acid and certain fetal treatments (such as an abnormal fetal rhythm).
Just because something crosses over (most things do), doesn't mean it will cause harm.
True or False: Healthy pregnant women are at normal risk of severe COVID-19 infection.
False.
Healthy pregnant women are at increased risk of having a serious life-threatening COVID-19 infection. This includes increased risk of ICU admission, mechanical ventilation, extracorporeal membrane oxygenation (ECMO), and death. The CDC acknowledges that pregnancy alone is a high risk condition.
True or False: The fetus is unaffected by COVID-19 infection in the mother.
False.
While COVID-19 probably does not cross the placenta and cause a congenital infection in the baby like CMV does, it definitely affects the fetus. Studies show that maternal COVID-19 increases risk of stillbirth, preterm birth and cesarean delivery. Heck, I even did a meta-analysis on this!
True or False: The COVID-19 vaccine is protective for the fetus.
True (maybe).
The vaccine's job is to generate antibodies. Some of these antibodies cross the placenta (especially IgG).
We give Tdap vaccine for just this reason: the patient generates antibodies against the Whooping Cough Virus, passes it along to her fetus, and the newborn is now protected from a potentially deadly infection. This is called passive immunity. Influenza vaccine works the same way but the main reason is that pregnant people at at 40% increased risk of getting VERY sick from influenza.
Vaccines... such a beautiful thing to gift your child.
True or False: I can still decline the vaccine.
True.
This is elective. No one is mandating you to get a vaccine. I will support your decision, and your doctor should, too.
Resources and References
The hyperlinks below will take you to important documents!
Center for Disease Control and Prevention on COVID-19 and pregnancy.
Center for Disease Control and Prevention on COVID-19 vaccine.
Center for Disease Control and Prevention on Vaccines in pregnancy.
Royal College of Obstetricians and Gynecologists: updated advice on COVID-19 vaccine in pregnant and breastfeeding women. (accessed 1/5/2021)
If you have any questions, leave them below!
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