Planning a pregnancy when you have an autoimmune disease isn’t about giving up your treatment-it’s about making smart, informed choices that protect both you and your baby. For years, the default advice was to stop all medications before conceiving. But that mindset is outdated. Today, we know that uncontrolled disease is far more dangerous than most medications used to manage it. The real risk isn’t the drug-it’s the flare.
Why Stopping Medication Can Be Riskier Than Taking It
Many women with lupus, rheumatoid arthritis, or other autoimmune conditions worry that any medication during pregnancy could harm the baby. But research shows the opposite: stopping effective treatment often leads to disease flares, which carry serious risks. A flare during pregnancy can increase your chance of preeclampsia by 3 to 5 times, raise the risk of preterm birth before 34 weeks by nearly 3 times, and lead to low birth weight or stillbirth. A 2022 study in Arthritis & Rheumatology found that women who kept taking hydroxychloroquine during pregnancy cut their risk of lupus flares by 66% and reduced preterm birth rates by half. Meanwhile, women who stopped their TNF inhibitors-like adalimumab or etanercept-before conception had a 63% chance of experiencing a flare, compared to just 20% of those who continued. That’s not a small difference. That’s the difference between a healthy pregnancy and one that requires intensive care.Which Medications Are Safe? The Clear Winners
Not all drugs are created equal when it comes to pregnancy. Here’s what the latest data says about the most commonly used treatments:- Hydroxychloroquine (Plaquenil): Used for lupus and rheumatoid arthritis, this drug has been tracked in over 12,450 pregnancies with no increase in birth defects. It’s so safe that experts now recommend continuing it throughout pregnancy-even starting it before conception if you’re planning to get pregnant.
- Azathioprine: Commonly used for lupus nephritis and other severe autoimmune conditions. Across more than 5,800 pregnancies, it showed a 95.3% safety rate. The risk of preterm birth was only 2.1% in women taking it, compared to 8.7% in those with active disease.
- Sulfasalazine: Often used for inflammatory bowel disease and arthritis. Over 3,200 pregnancies show no signs of harm. It’s considered one of the safest options.
- TNF inhibitors (adalimumab, etanercept, certolizumab pegol): These are among the most studied biologics in pregnancy. Certolizumab pegol stands out because it barely crosses the placenta-just 0.2% of the mother’s blood level reaches the baby. Adalimumab and infliximab cross more, but even then, they’ve been used safely in over 28,000 pregnancies with no increased risk of major birth defects.
- Corticosteroids (prednisone): Used for flares, low doses (under 20mg/day) are generally safe. Higher doses may increase gestational diabetes or high blood pressure risk, so they’re used only when necessary.
Medications to Avoid-Before and During Pregnancy
Some drugs have clear, serious risks. These are not up for debate:- Methotrexate: This drug is a known teratogen. In over 340 documented cases, it caused major birth defects including cleft palate, missing limbs, and skull abnormalities. It must be stopped at least 3 months before trying to conceive. Even one dose during early pregnancy can be dangerous.
- Mycophenolate mofetil (CellCept): Linked to a 24.4% risk of birth defects, including ear, eye, and jaw abnormalities. The FDA added a black box warning in 2023. You need to switch to a safer alternative at least 6 weeks before conception.
- JAK inhibitors (tofacitinib, upadacitinib): EULAR and the FDA recommend avoiding these entirely during pregnancy due to theoretical risks. Japan’s guidelines are an outlier, allowing upadacitinib in the first trimester based on limited data-but most U.S. doctors still advise stopping them before conception.
Timing Matters: When to Switch Medications
You can’t just stop a drug cold turkey and expect your body to adjust. Switching medications takes time. Here’s what to plan for:- Methotrexate: Stop at least 3 months before trying to conceive. This gives your body time to clear it completely.
- Mycophenolate: Switch at least 6 weeks before conception. Some doctors recommend 8-12 weeks for extra safety.
- Biologics: You don’t need to stop most of them. But if you’re on adalimumab or infliximab, your doctor might suggest pausing around week 30 of pregnancy to reduce the amount passed to the baby before delivery. Certolizumab pegol doesn’t need this pause-it’s safe all the way through.
What About Breastfeeding?
Many women worry that taking medication means they can’t breastfeed. That’s not true. Over 98% of biologics, including adalimumab, etanercept, and certolizumab, pass into breast milk in amounts too small to matter. In one study, adalimumab levels in breast milk were only 0.005% to 0.13% of the mother’s blood concentration. That’s less than a drop in a swimming pool. The American Academy of Pediatrics and the European Alliance of Associations for Rheumatology both say breastfeeding is safe while on these drugs. You don’t need to pump and dump. In fact, continuing your medication while nursing helps keep your disease under control, which is better for you-and your baby.The Power of Preconception Planning
The best time to talk about medication safety is not when you’re already pregnant. It’s months-or even a year-before you start trying. A 2022 study from the Lupus Foundation found that women who saw both a rheumatologist and a maternal-fetal medicine specialist before conception had:- 53% fewer unplanned medication changes
- 37% higher rates of full-term births
- Lower rates of hospitalization during pregnancy
What You Should Do Right Now
If you’re thinking about pregnancy-or even just considering it in the next year-here’s your action plan:- Don’t stop your meds on your own. Many women quit because they’re scared. That’s how flares happen.
- Schedule a preconception visit with your rheumatologist. Bring your current medication list.
- Ask for a referral to a maternal-fetal medicine specialist. This isn’t optional-it’s essential.
- Confirm your drug safety using the latest EULAR 2024 guidelines. If your doctor is still using advice from 2018, ask for an update.
- Track your disease activity. If you’ve had a flare in the last 6 months, wait until you’re stable before trying to conceive.
- Use reliable resources. The Arthritis Foundation, MotherToBaby, and the Lupus Foundation of America have free, evidence-based guides for pregnancy planning.
Real Stories, Real Outcomes
One woman on MyHealthTeams wrote: "Continued hydroxychloroquine throughout pregnancy-baby born at 39 weeks, 7 lbs 10 oz, zero complications." Another shared: "Stopped adalimumab at 8 weeks because my OB said to. Had a severe flare at 20 weeks. Ended up on 20mg prednisone. Got gestational diabetes. Delivered at 34 weeks." The difference? One followed the science. The other followed outdated advice.What’s Coming Next
The field is moving fast. In January 2024, the NIH launched a $12.7 million research network focused on newer drugs like JAK inhibitors and biosimilars. EULAR will release a patient decision tool in late 2024. ACOG plans to update its guidelines in mid-2025 to match the latest evidence. There’s also a new prediction tool being used in clinics that calculates your personal risk of flare during pregnancy based on 12 factors-your disease history, lab results, medication use, and more. It’s 87% accurate. This isn’t guesswork anymore. It’s personalized medicine.You’re Not Alone
You’re not the first woman with an autoimmune disease to get pregnant. You’re not the first to worry. But now, you have better tools than ever before. The goal isn’t to be perfect. It’s to be informed. To work with your team. To make choices based on data, not fear. The truth is simple: You can have a healthy pregnancy. You can stay on the medication that keeps you well. And your baby can be just as healthy as any other.Can I keep taking my autoimmune medication while pregnant?
Yes, most autoimmune medications are safe during pregnancy. Hydroxychloroquine, azathioprine, sulfasalazine, and many biologics like certolizumab pegol have strong safety data across thousands of pregnancies. The key is to plan ahead-don’t stop or switch meds without talking to your rheumatologist.
What if I got pregnant unexpectedly while on methotrexate or mycophenolate?
Stop the medication immediately and contact your rheumatologist and OB-GYN right away. While these drugs carry risks, not every exposure leads to birth defects. Your medical team will monitor your pregnancy closely with detailed ultrasounds and possibly amniocentesis if needed. Many women in this situation go on to have healthy babies.
Is it safe to breastfeed while on biologics like Humira or Enbrel?
Yes. Studies show that biologics like adalimumab and etanercept pass into breast milk in extremely small amounts-less than 0.13% of the mother’s blood level. These drugs are large proteins that don’t get absorbed well by a baby’s gut. The American Academy of Pediatrics and EULAR both confirm breastfeeding is safe while on these medications.
Should I stop my biologic after 32 weeks of pregnancy?
No-there’s no evidence that continuing biologics past 32 weeks increases infection risk in newborns. A 2021 study of over 14,000 infants found identical infection rates whether mothers took TNF inhibitors up to delivery or stopped early. Certolizumab pegol can be continued throughout pregnancy. For adalimumab or infliximab, your doctor might suggest stopping after 30 weeks to reduce fetal exposure, but this isn’t required.
What’s the best time to see a specialist before getting pregnant?
At least 6 months before trying to conceive. This gives enough time to switch medications if needed, stabilize your disease, and create a clear plan. If you’re already on a safe drug, a preconception visit ensures you’re on the right dose and ready for pregnancy. Waiting until you’re pregnant means you’re playing catch-up-and that’s riskier.
One comment
Let me get this straight-you’re telling me it’s *safe* to keep taking biologics while pregnant? That’s not medicine, that’s gambling with a baby’s life. I’ve seen too many kids born with defects because moms were too lazy to go off their drugs. This isn’t ‘informed choice,’ it’s corporate propaganda disguised as science. The FDA didn’t greenlight this stuff because it’s safe-it’s because they’re pressured by Big Pharma. Don’t let anyone tell you otherwise.
While the empirical data presented is indeed compelling, one must not conflate statistical safety with ontological certainty. The longitudinal effects of biologic exposure on epigenetic expression remain inadequately studied. To assert that hydroxychloroquine or azathioprine are ‘safe’ is to impose a reductive biomedical paradigm upon a profoundly complex biological continuum. The absence of evidence is not evidence of absence.