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Influenza in Pregnancy: Prevention and Treatment

  • Practice Advisory PA
  • August 2025

Replaces Committee Statement Number 7, February 2024

Last updated October 2025

This Practice Advisory was developed by the American College of Obstetricians and Gynecologists’ Immunization, Infectious Disease, and Public Health Preparedness Expert Work Group in collaboration with Neil S. Silverman, MD, FACOG, Flor M. Munoz, MD, Rhoda Sperling, MD, FACOG, and Linda Eckert, MD, FACOG.

Summary of Updates

This Practice Advisory provides an overview of guidance for the use of the annual influenza vaccine in prepregnant, pregnant, postpartum, and lactating individuals for the prevention of influenza infection and, particularly, the severe complications associated with it in pregnant people. Because the risks associated with influenza infection are increased for both pregnant patients and their newborns, the American College of Obstetricians and Gynecologists (ACOG) reinforces the importance of recommending and providing the influenza vaccine to all patients who will be pregnant during the respiratory illness season.  The new live-attenuated, intranasally administered influenza vaccine, which has recently been approved for home self-administration after having been exclusively prescribed and administered in a medical setting or a pharmacy, is not approved for use in pregnant individuals. However, it is approved for use in otherwise healthy individuals over the age of 2 and could be used for postpartum patients, including those who are lactating, who are averse to needle-based vaccines or prefer intranasal vaccine administration. For additional information regarding influenza infection, diagnosis, and treatment, see ACOG’s Influenza FAQs for Obstetrician–Gynecologists.

Key Recommendations

The American College of Obstetricians and Gynecologists makes the following recommendations and conclusions:

  • The American College of Obstetricians and Gynecologists continues to strongly recommend that all adults receive an annual influenza vaccine and, because the risks associated with influenza infection are increased for both pregnant patients and their newborns, that individuals who are or will be pregnant during influenza season receive an inactivated or recombinant influenza vaccine as soon as it is available. Influenza season is typically September through April, although seasonal variability is not uncommon.
  • Ideally, influenza vaccination should be given before the onset of influenza circulation in the community, but vaccination at any time during the influenza season is encouraged to ensure protection during the period that the virus is circulating in the community. Providers should be able to access reports from local public health agencies that provide information regarding influenza cases and season duration in their region, to optimize timely access to influenza vaccine for their patients.
  • The influenza vaccine can safely be administered at the same time as other vaccines recommended during pregnancy, such as the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine; respiratory syncytial virus (RSV) vaccine; or the current COVID-19 vaccine. The efficacy of co-administered vaccines is not impacted if they are given during the same office visit, and co-administration increases rates of overall vaccination uptake.
  • Patients who decline or were not vaccinated against influenza during pregnancy should be encouraged to consider vaccination postpartum. They will still benefit from the immunity conferred by the vaccine after their delivery, and their infants can still benefit from passive immunity via breastfeeding.
  • Obstetrician–gynecologists and other obstetric care professionals should continue to confidently recommend influenza vaccination and counsel pregnant individuals about the benefits of influenza vaccination for themselves. They should also continue to emphasize the benefits of passive immunity for newborns whose mothers received prenatal immunization, as well as from mothers who were vaccinated before delivery and who breastfeed.
  • Obstetrician–gynecologists and other obstetric care professionals should consider influenza, RSV, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as diagnoses for pregnant individuals who present with symptoms of respiratory illness during seasons in which these viruses are circulating.
  • Clinicians should initiate empiric antiviral treatment as soon as possible, ideally within 48 hours of symptom onset, for all pregnant individuals with suspected influenza.
  • Antiviral treatment should not be delayed while awaiting respiratory infection test results, and a patient’s vaccination status should not affect the decision to treat.
  • ACOG encourages clinicians to stock and, ideally, administer the influenza vaccine along with all routinely recommended maternal vaccines in their offices.

Background

Pregnant and postpartum individuals are at significantly higher risk of serious complications related to seasonal and pandemic influenza infections compared with nonpregnant people. This increased risk also has been seen for other respiratory infections, including SARS-CoV-2, and is amplified if a pregnant individual has underlying health conditions. Established potential complications of influenza during pregnancy include pneumonia, hospital or intensive care unit admission, preterm delivery, and maternal and fetal death (Callaghan 2015; Oboho 2016). Influenza vaccination, as an integral component of prenatal and postpartum care, continues to be recommended by ACOG and other national medical organizations as the safest and most effective way to prevent influenza infection and reduce related maternal morbidity and mortality, as well as obstetric complications (Grohskopf 2022; Thompson 2014; Regan 2016).

Vaccination and Timing

Influenza vaccination remains an essential element of prepregnancy, prenatal, and postpartum care. The American College of Obstetricians and Gynecologists strongly reinforces the recommendation that individuals who are or will be pregnant during influenza season receive the seasonally updated influenza vaccine at any time during pregnancy. In the United States, the influenza season typically occurs from September through April. Ideally, influenza vaccination should be given before the onset of influenza circulation in the community. However, vaccination at any time during the influenza season is recommended to ensure protection during the period that virus is circulating in the community. Pregnant individuals who are in the third trimester as respiratory illness season begins should receive that season’s influenza vaccine as soon as vaccines are available (usually August to September) to optimize protection for themselves and for their newborns, who will be delivered during influenza season.

Inactivated influenza vaccines can be given to all pregnant individuals during any trimester of gestation (Grohskopf 2022). Pregnant individuals should be vaccinated even if they received an influenza vaccine during a previous pregnancy or in the previous year’s influenza season. Circulating influenza virus strains can change from season to season. As a result, annual vaccination with the vaccine selected to best match the current circulating strains needs to be administered every year to ensure strain-specific immunity for the duration of the season. Furthermore, the antibody-based immunity conferred by any single influenza vaccine dose decreases over time and from one season to the next, and annual vaccination is necessary to ensure optimal immunity with each influenza season.

Safety and Efficacy of Vaccination

Vaccination during pregnancy has been demonstrated repeatedly in large studies to safely protect pregnant people and their newborns against PCR-confirmed influenza illness and complications (Zaman 2008; Tapia 2016, Sahni 2024). While no vaccine can prevent all infections, the influenza vaccine has been consistently shown to lower the risk of severe disease and influenza-related hospitalizations for vaccinated pregnant individuals and their infants. Vaccination in the postpartum period is recommended for individuals who did not receive the vaccine during pregnancy, as influenza can cause severe disease in the first 2–6 weeks postpartum. While both vaccination in pregnancy and vaccination postpartum can result in the production of antibodies present in breast milk, with postpartum vaccination the newborn will not have the full benefit of passive protection from vaccine-induced maternal antibodies, transferred transplacentally from the mother to the fetal bloodstream (Hunagund 2022; Zheng 2022; Atyeo 2021).

Pregnant individuals should receive any licensed, recommended, age-appropriate, inactivated or recombinant influenza vaccine during any trimester (Grohskopf 2022). The influenza vaccine can safely be administered at the same time as other vaccines recommended during pregnancy, such as the Tdap, RSV, or current COVID-19 vaccine. The efficacy of co-administered vaccines is not impacted if they are given during the same office visit, and co-administration increases rates of overall vaccination uptake (Perego 2021). It is also safe for lactating individuals to receive the influenza vaccine if they did not receive it during pregnancy.

Numerous studies, including randomized controlled clinical trials and observational studies, as well as data from safety-reporting systems, have consistently demonstrated the safety of influenza vaccination during pregnancy (CDC MMWR 2013; Tamma 2009; Carcione 2013; Moro 2011; Bednarczyk 2012). The efficacy of seasonal influenza vaccination in pregnant individuals is similar to its efficacy among the nonpregnant adult population (Thompson 2014).

Influenza vaccination also benefits the newborn when it is administered during pregnancy. Large-scale randomized controlled clinical trials and numerous observational studies have demonstrated neonatal protection from maternal influenza vaccination (Zaman 2008; Madhi 2014; Tapia 2016; Steinhoff 2017). Studies also have demonstrated a reduction in hospitalization related to influenza among infants born to women who received the vaccine during pregnancy (Black 2004; Benowitz 2010).

Importantly, studies consistently demonstrate that, when recommendations for influenza vaccination during pregnancy come directly from a patient’s obstetrician–gynecologist or other obstetric care professional, and the vaccine is available in the clinician’s office, the odds of vaccine acceptance and receipt are 5-fold to 50-fold higher (Ahluwalia 2010; Shavell 2012). Therefore, obstetrician–gynecologists and other obstetric care professionals should confidently recommend influenza vaccination and counsel pregnant individuals about the benefits of influenza vaccination for themselves, and the benefits of passive immunity for their newborns as conferred by transplacental transfer of maternal antibodies resulting from prenatal maternal immunization. They should also endeavor to make vaccination as easy a process as possible for patients, ideally ensuring vaccine availability in the same location that prenatal care is provided (Malik 2023; Bianchi 2022).

Storage and Administration

ACOG encourages clinicians to stock and, ideally, administer all recommended vaccines in their offices. Studies show that immunization rates are higher when a trusted clinician can strongly recommend, offer and administer the vaccine during the same visit, as opposed to recommending vaccination and referring the patient elsewhere to receive the vaccine. Influenza and Tdap vaccines are routinely offered and administered by a majority of practices, while other vaccines are not as commonly stocked, leaving significant gaps in coverage (CDC 2024, O’Leary 2019). When clinicians make immunizations an integral part of their practice and routinely recommend and administer an indicated vaccine, they help to increase vaccination rates for pregnant people.

Many obstetrician–gynecologists also perceive a lack of reimbursement as a major barrier to including immunization services in their practices (Leddy 2009). However, with proper documentation and coding, these services can be reported to third-party payers and reimbursement can be received. The practice should adhere to basic coding principles when billing for immunization services. In general, the appropriate vaccine product code should always be reported along with the appropriate Current Procedural Terminology (CPT) vaccine administration code.

Obstetrician–gynecologists have a unique opportunity to reduce the frequency of vaccine-preventable diseases. To accomplish that goal, clinicians must be aware of current vaccine recommendations, educate patients about vaccination, encourage patients to be vaccinated, and institute systems in the office to integrate vaccination into the routine running of their practice.

For more information on coding, please visit, Immunization Coding for Obstetrician-Gynecologists.

Intranasal Self-Administered Vaccine

The live-attenuated, intranasally administered influenza vaccine, which has recently been approved for home self-administration after being prescribed and dispensed in a pharmacy, is not approved for use in pregnant individuals. However, it is approved for use in otherwise healthy individuals over the age of 2 and could be used for postpartum patients, including those who are lactating, who are averse to needle-based vaccines or prefer intranasal vaccine administration. In addition, there is no risk to a pregnant person or her fetus if children or other individuals in their household have received a live-attenuated intranasal influenza vaccine (Perego 2021; CDC 2022).

Respiratory Infection Treatment During Pregnancy

Clinicians should initiate empiric antiviral treatment as soon as possible, ideally within 48 hours of symptom onset, for all pregnant individuals with suspected influenza. Antiviral treatment should not be delayed while awaiting respiratory infection test results, and a patient's vaccination status should not affect the decision to treat. Although the influenza vaccine reduces the risk of severe disease, it will not prevent all infections.

Patients with moderate or high risk of severe illness should be seen in an ambulatory setting for in-person evaluation as soon as possible. For all patients, oseltamivir (commonly known by its original brand name Tamiflu, but currently available in an equivalent generic form for prescribing) is the preferred influenza antiviral treatment for pregnant individuals (75 mg orally twice daily for 5 days), assuming there is sufficient supply, and the prevalence of resistant circulating viruses is low. Zanamivir also may be prescribed (two 5-mg inhalations [10 mg total] twice daily for 5 days), or, alternatively, peramivir may be administered (one 600-mg dose by intravenous infusion for 15–30 minutes) (CDC 2023). Peramivir may be considered as the optimal first-line therapy specifically for ill hospitalized patients who require ventilatory assistance or are unable to take oral medications (CDC 2023). Another influenza treatment, baloxavir, is not recommended for pregnant people due to the absence of efficacy and safety data in this population (CDC 2023). Treatment can be discussed over the phone with patients who are not severely ill, and a prescription provided either by phone to a pharmacy or through the patient’s electronic medical record, if available.

If a pregnant patient tests positive for SARS-CoV-2 infection, obstetric care professionals should discuss and offer Paxlovid (nirmatrelvir and ritonavir, only available by the brand name) to mitigate the severity of infection, as well as to lower the risk of long COVID (Garneau 2022; Bhatia 2025; Wang 2025; Wang 2024; Mandel 2025; CDC 2025). The dosage for Paxlovid in patients with normal renal function is 300 mg of nirmatrelvir (two 150-mg tablets) with 100 mg of ritonavir (one 100-mg tablet), with all three tablets taken together twice daily for 5 days (Pfizer Labs 2025). Dose adjustments for patients with moderate renal impairment have also been established, with the nirmatrelvir component lowered by half, to one 150-mg tablet twice daily (Medscape). Obstetrician–gynecologists should ensure that the patient has no contraindications and should review any possible drug–drug interactions and how to handle them before prescribing Paxlovid. If there is suspected or confirmed co-infection with influenza and SARS-CoV-2, both oseltamivir and Paxlovid should be prescribed and can be taken together. There are no clinically significant drug–drug interactions between the antiviral agents or immunomodulators that are used to prevent or treat SARS-CoV-2 and the antiviral agents that are used to treat influenza.

Obstetrician–gynecologists and other obstetric care professionals should refer to ACOG recommendations frequently for influenza and SARS-CoV-2 treatment recommendation updates (CDC 2023; CDC 2025).

Postexposure Chemoprophylaxis for Influenza

Because of the high potential for morbidity and mortality related to influenza infection for pregnant and postpartum patients, postexposure antiviral chemoprophylaxis for influenza can be considered for pregnant individuals and those who are up to 2 weeks postpartum (including after pregnancy loss) who have had close contact with infectious individuals. The chemoprophylaxis dosing recommendation is oseltamivir at 75 mg once daily for 7 days after the last known exposure (CDC 2023). Generally, postexposure chemoprophylaxis for persons should be used only when antivirals can be started within 48 hours of the most recent exposure and prior to symptom onset (CDC 2023). Individuals receiving antiviral chemoprophylaxis should be encouraged to seek medical evaluation as soon as they develop a febrile respiratory illness that might indicate influenza. In addition, in individuals with frequent exposures, early treatment as opposed to prophylaxis may be considered (CDC 2023). Finally, at-risk family members of patients with an influenza diagnosis should be referred to their health care professionals for consideration of antiviral chemoprophylaxis.

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All ACOG committee members and authors have submitted a conflict-of-interest disclosure statement related to this published product. Any potential conflicts have been considered and managed strictly in accordance with ACOG's Conflict of Interest Disclosure Policy. The ACOG policies can be found on acog.org. The American College of Obstetricians and Gynecologists has neither solicited nor accepted any commercial involvement in the development of the content of this published product.

A Practice Advisory is a brief, focused statement issued to communicate a change in ACOG guidance or information on an emergent clinical issue (e.g., clinical study, scientific report, draft regulation). A Practice Advisory constitutes ACOG clinical guidance and is issued only on-line for Fellows but may also be used by patients and the media. Practice Advisories are reviewed periodically for reaffirmation, revision, withdrawal or incorporation into other ACOG guidelines.

This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on  www.acog.org  or by calling the ACOG Resource Center.

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The American College of Obstetricians and Gynecologists (ACOG), is the nation's leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, ACOG strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women's health care.  www.acog.org  

 
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