Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer.
So, if you're ready, let's jump right in.
Margaret Fitzgerald: A 33-year-old who's pregnant with her second child presents for prenatal care. She does not have a record of her immunizations but states she hasn't had any vaccines in more than a year. She's without complaint. An exam is consistent with gestational age, with fetal heart tones at 140 beats per minute and visible fetal activity. Today, which two vaccines are recommended?
A: Measles, mumps, rubella.
B: Varicella.
C: COVID 19.
D: Tdap or tetanus-diphtheria-acellular pertussis.
The correct answers are C: COVID 19 and D: Tdap. Where do we start? First, let's determine what kind of a question this is. This is a health promotion question, and it could also be looked at as a plan/intervention question and background information.
Of course, since we're talking about giving a medication which vaccines technically are during pregnancy, we have to ask the question, ‘What vaccines are safe to give during pregnancy?’ And, ‘Is there a compelling reason for using these vaccines during pregnancy?’ Unfortunately, there is a misconception that most, if not all, vaccines are unsafe to use during pregnancy. In reality, virtually all vaccines can be given during pregnancy, particularly if both mother and child will benefit from the immunization.
The notable exception in giving vaccines during pregnancy are that there are a handful of live virus vaccines that are still around. These vaccines are made from a weakened form of whatever pathogen it is. Just strong enough to boost immunologic response, but not strong enough to give the recipient the disease in adults. The only live virus vaccines that are given commonly now are MMR, which provides protection against measles, mumps, and rubella, rubella being German measles, and the varicella vaccine, which has protection against chickenpox.
Now, why don't we use these during pregnancy? Because there is a theoretical, but not an actual risk, of passing the virus in these live virus vaccines on to the fetus. Please note I said theoretical, not actual, as there has never been a case of congenital varicella syndrome nor congenital rubella syndrome, the two most worrisome of these viruses noted in the offspring of a woman who might have inadvertently received these vaccines during pregnancy. In the past decade there's been a movement towards immunizing women during pregnancy with the idea that mom will mount an antibody response and then pass those antibodies across the placenta. And now our baby, her newborn, will be protected against whatever disease mom was immunized against.
There's also a growing appreciation for the fact that certain common infections such as influenza and COVID 19 are much more harmful to a woman during pregnancy than in an age match-controlled who's not pregnant. Indeed, the risk of hospitalization from influenza related complications in a woman during pregnancy is about five times that of an age matched non-pregnant woman.
The data are emerging about COVID 19, but at the same time, there is a higher rate of maternal death, preterm birth, and a number of other pregnancy related complications in women who have contracted COVID 19 during pregnancy. In the case of COVID 19 vaccine, as well as the influenza vaccine, the goal of giving during the pregnancy is to protect both mom and the offspring as the antibody will be passed across the placenta.
In the case of the Tdap vaccine, this is given every pregnancy in the third trimester, whether the pregnant individual would need the vaccine in the day-to-day. So, let me give you a better example of that. If you were to see a person who gave birth 2 years ago, had a Tdap in the last trimester of pregnancy, then that person is adequately protected against tetanus as well as to diphtheria and pertussis.
However, the same person would still be recommended to get Tdap in a subsequent pregnancy, even if the last year was only a year or 2 years before the express goal of giving that extra Tdap in the third trimester of subsequent pregnancies, is specifically to boost maternal pertussis antibodies so she can pass those antibodies across the placenta and the newborn will arrive with pertussis protection on board.
Influenza, COVID 19, and pertussis are all serious illnesses in the first few months of life. Indeed, that risk really extends into the first entire year of life. With all of these conditions maternal immunization has been noted to dramatically reduce the risk of life-threatening disease in the infant, particularly in those first 6 months of life. The latest vaccine to be added to the list of immunizations to be given in later pregnancy, is the vaccine against RSV.
Currently, it's not known how much RSV protection that this gives the pregnant individual, but it's the use of the RSV vaccine in later pregnancy is known to reduce the risk of serious RSV-related disease in the first 6 months of life by at least 70%. And the interesting thing is the reduction of the risk of serious influenza-related illness in the first 6 months of life is reduced by about 70 to 80%, with mom getting the vaccine during pregnancy.
And of course, we do start immunizing the little squirts at 2, 4, and 6 months with diphtheria, tetanus, and pertussis vaccine. They really don't mount much of an antibody response till they get to like their third shot. And of course, we can start immunizing the little ones against influenza and COVID 19 once they hit the 6 months of life.
And I would advocate for that. This is background information. Let’s take a look at the question and the choices given.
A 33-year-old who's pregnant with her second child presents for prenatal care. She does not have her record of her immunization, but states who hasn't had any vaccines in more than a year. She's without complaint and exam is consistent with gestational age, with fetal heart tones at 140 beats per minute, visible fetal activity today, which two vaccines are recommended?
A: MMR or measles, mumps, rubella vaccine.
This is, of course, incorrect because this is a live virus vaccine. As I mentioned, even though the risk to the fetus is more theoretical than actual, the use of live virus vaccines during pregnancy is not endorsed. However, if mom had never been protected against MMR, she can get that vaccine once she gives birth and it's okay to use during breastfeeding.
B: Varicella
One more time, varicella vaccine is a live virus immunization and its use is not recommended during pregnancy. One more time, however, varicella is fine to give during breastfeeding.
C: COVID 19.
And of course this is one of the correct answers. Keep in mind, the COVID vaccine can be given at any time during pregnancy. This is to protect the pregnant individual who's at higher risk for pregnancy-related complications if the person comes down with COVID 19 while pregnant, and a marked increase at the risk of giving birth preterm.
Obviously preterm birth creates a situation where there are more problems in the newborn. I would say, one more time, the same information. If we were given a choice of giving the flu vaccine rather than the COVID 19 vaccine, in a question like this, because of the higher risk for maternal mortality and morbidity when contracting influenza during pregnancy.
And I also just want to throw in one more point. Remember, once a person gives birth, the body doesn't automatically say, ‘We're good to go.’ No problems here. But it takes the body a couple of weeks to figure out it's still not pregnant. And therefore, the first 2 weeks postpartum also pose a very high-risk period for severe maternal illness with COVID 19, with influenza, and a number of other conditions.
Option D: Tdap.
Obviously, this is the other correct answer. Let's say that we didn't have any immunization record and we found this patient received a Tdap two years ago. We would still give a Tdap today to boost maternal pertussis antibodies to protect the little one.
But without a pregnancy any adults who received the Tdap 2 years ago would be considered up-to-date on this type of protection. Key takeaway: any medication or immunization given during pregnancy can be a daunting task. To think about is to think about the best choices to discuss with the patient so that the patient is making an informed decision. However, recognize that research backs up that nearly all vaccines are acceptable to use during pregnancy, and that the yield can include improved maternal as well as infant outcomes.
Voiceover: Thank you for listening to NP Certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast and for more NP resources, visit FHEA.com.