COVID-19 Vaccines in Pregnancy

updated September 23, 2021

We have several podcasts on the vaccine and specifically in pregnancy. Increasing information on safety has become available, but the basic principles in those podcasts still stand. Podcast on vaccine candidates, podcast on vaccines in pregnancy and lactation, update on vaccines in pregnancy. In May 2021, a large CDC registry of the COVID-19 vaccine in pregnancy was published by Shimabukuro et al. The CDC is tracking pregnant patients who receive the COVID-19 vaccine in 2 ways: (1) the V-safe program (enroll at time of immunization using QR code provided in materials you receive and (2) a pregnancy registry (~5,000 individuals enrolled out of initial V-safe pregnancy population. In the pregnancy registry, the CDC is calling pregnant patients each trimester and post-partum and obtaining records from the obstetric provider. These data have demonstrated no increased risk of pregnancy loss, preterm birth, or congenital anomalies. Of note, many of the pregnancies were not complete at that time, as individuals immunized in the first trimester still had ongoing pregnancies. These data are demonstrated in the graphics below.

The American College of Obstetrics and Gynecology (ACOG) released an updated statement on July 30, 2021 that: recommends that pregnant and lactating individuals be vaccinated against COVID-19. Additionally, the document reinforces that the claims linking COVID-19 vaccines to infertility are unfounded and have no scientific evidence supporting them, recommending vaccination for all eligible people who may consider future pregnancy. Further, although women < 50 years old may receive any COVID-19 vaccine, there is an increased but very rare risk of thrombosis with thrombocytopenia syndrome after the Janssen/Johnson & Johnson vaccine and they may opt for an mRNA vaccine instead (Pfizer or Moderna). The Society for Maternal-Fetal Medicine (SMFM) supports these statements.

A multidisciplinary group at the University of Massachusetts Medical School-Baystate has created decision aids to help pregnant people decide if the COVID-19 vaccine is right for them, which can be found here in 10 languages.

Recurrent, Low-Risk Chest Pain GRACE Guidelines

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The Society for Academic Emergency Medicine has released new Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE). These guidelines are aimed at de-implementing low-value care to reduce wasteful medical care. The first guidelines, GRACE-1, target recurrent low-risk chest pain and are published in Academic Emergency Medicine (Musey et al). Previously we covered the American College of Emergency Physician’s clinical policy on non-ST elevation acute coronary syndromes, which does not specifically address recurrent chest pain.

Panscan After Out of Hospital Cardiac Arrest

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Panscans, or a combination of head to pelvis CT scans, have been used in patients following significant trauma. Recent attention has shifted to the utility of routine CT scans following cardiac arrest. This is based on (1) identification of potential causes of cardiac arrest (2) identification of complications of resuscitation. In this episode, we cover an article by Branch et al in Academic Emergency Medicine.

Vaccine-Induced Thrombotic Thrombocytopenia

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In this episode, we discuss thrombotic thrombocytopenia associated with the viral vector COVID-19 vaccines (VITT: Vaccine-Induced Thrombotic Thrombocytopenia) – a very very rare, but real entity. Information is still emerging so numbers will likely change in the coming days. For more on cerebral vein thrombosis in general, check out this podcast.

Greinacher et al NEJM 2021
Schultz et al. NEJM 2021
ACIP Presentation by Jannsen 4/14/21, Muir et al NEJM 2021

International Society of Thrombosis and Hemostasis Statement

United Kingdom Guidance On Thrombosis Following Vaccinations

Cerebral Vein Thrombosis

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If you’re looking for vaccine-induced thrombotic thrombocytopenia (CVT/CVST with thrombocytopenia following AstraZeneca or J&J COVID-19 vaccine), check out this podcast.

Multicenter Cohort Study: Ferro JM et al. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke. 2004 Mar;35(3):664-70. Epub 2004 Feb 19. PMID: 14976332.

Utility of D-dimer:

  1. Dentali F et al. D-dimer testing in the diagnosis of cerebral vein thrombosis: a systematic review and a meta-analysis of the literature. J Thromb Haemost. 2012 Apr;10(4):582-9.PMID: 22257124.
  2. Meng R et al. Evaluation of plasma D-dimer plus fibrinogen in predicting acute CVST. Int J Stroke. 2014 Feb;9(2):166-73. Epub 2013 Mar 19. PMID: 23506130

Tranexamic acid in epistaxis

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In this episode we cover the literature on tranexamic acid (TXA) in epistaxis, including a new trial in Annals of Emergency Medicine by Reuben et al, the NoPac trial.

Other references include:

  1. Tibbelin et al. Effect of local tranexamic acid gel in the treatment of epistaxis. ORL J Otorhinolaryngol Relat Spec. 1995 Jul-Aug;57(4):207-9. PMID: 7478455.
  2. Zahed et al.A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013 Sep;31(9):1389-92. doi: 10.1016/j.ajem.2013.06.043. Epub 2013 Jul 30. PMID: 23911102.
  3. Atabaki et al. A Comparative Study on the Effect of Topical Phenylephrine with Topical Tranexamic Acid in Management of Epistaxis. Nurs Midwifery J. 2017; 15 (7) :488-496
  4. Zahed R, et al. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med. 2018 Mar;25(3):261-266. doi: 10.1111/acem.13345. Epub 2017 Dec 9. PMID: 29125679.
  5. Akkan S et al. Evaluating Effectiveness of Nasal Compression With Tranexamic Acid Compared With Simple Nasal Compression and Merocel Packing: A Randomized Controlled Trial. Ann Emerg Med. 2019 Jul;74(1):72-78. doi: 10.1016/j.annemergmed.2019.03.030. Epub 2019 May 9. PMID: 31080025.
  6. Amini et al. Topical Tranexamic Acid versus Phenylephrine-lidocaine for the Treatment of Anterior Epistaxis in Patients Taking Aspirin or Clopidogrel; a Randomized Clinical Trial. Arch Acad Emerg Med. 2020 Nov 19;9(1):e6. PMID: 33313573; PMCID: PMC7720853.
  7. Whitworth et al. Comparative Effectiveness of Topically Administered Tranexamic Acid Versus Topical Oxymetazoline Spray for Achieving Hemostasis in Epistaxis. J Emerg Med. 2020 Feb;58(2):211-216.