When you have an autoimmune disease and are thinking about getting pregnant, the biggest question isn’t just can I get pregnant? It’s can I stay healthy-and can my baby?
For years, the advice was simple: stop all your meds. But that advice is outdated. In fact, stopping your medication without a plan can be riskier than keeping it. The latest research shows that uncontrolled disease poses a far greater threat to both mother and baby than most of the drugs used to manage it.
Why This Isn’t Just About Stopping Pills
Autoimmune diseases like lupus, rheumatoid arthritis, and psoriatic arthritis don’t just go away when you get pregnant. In fact, they often flare. And when they do, the risks go up: preterm birth, preeclampsia, low birth weight, even stillbirth. A study from Duke University found that women with active lupus during pregnancy were three to five times more likely to develop preeclampsia than those whose disease was under control. The same study showed that hydroxychloroquine, a common lupus drug, cuts flare risk by 66% and lowers the chance of preterm birth by half.
So here’s the truth: it’s not about avoiding medication. It’s about choosing the right ones-at the right time.
What Medications Are Safe? The Data Doesn’t Lie
Let’s cut through the noise. There are now clear, evidence-based guidelines from the European Alliance of Associations for Rheumatology (EULAR), updated in February 2025, that cover 47 different drugs. Here’s what the numbers say:
- Hydroxychloroquine (used for lupus and RA): 98.7% safety rate across over 12,000 pregnancies. No increase in birth defects. It’s so safe, it’s recommended to continue-even through breastfeeding.
- Azathioprine: 95.3% safe. Only 2.1% of babies born to moms on this drug were preterm, compared to 8.7% if the disease itself was active.
- Sulfasalazine: 97.1% safe. No signs of harm to the baby.
- TNF inhibitors (adalimumab, infliximab, etanercept, certolizumab): 94.8% safe across nearly 30,000 pregnancies. But not all are equal. Certolizumab pegol transfers almost nothing to the baby-just 0.2% of the mom’s blood level. Adalimumab? 15.7%. Infliximab? 23.4%. That’s why certolizumab is often preferred for third-trimester use.
And here’s the kicker: if you stop your TNF inhibitor before pregnancy, you have a 63% chance of a flare. If you keep it? Only 20%.
The Drugs You Must Stop-Before You Get Pregnant
Some medications are dangerous during pregnancy. Not because they’re “bad,” but because they’re too powerful. These are not up for debate:
- Methotrexate: This one is a hard stop. It’s linked to 17.8% risk of major birth defects-cleft palate, missing limbs, skull deformities. You need to stop it at least three months before trying to conceive.
- Mycophenolate: This one is even scarier. It causes serious birth defects in 24.4% of cases-missing ears, eye problems, heart defects. The FDA added a black box warning in March 2023. You need to switch at least six weeks before conception, but many doctors recommend three months.
- JAK inhibitors (tofacitinib, upadacitinib): EULAR says avoid entirely. Japan’s guidelines say it might be okay in the first trimester, but U.S. and European experts say the risk isn’t worth it. No one’s saying “yes” here yet.
Here’s what patients tell us: women who stopped methotrexate on their own, without doctor guidance, often had unplanned pregnancies and ended up with scary outcomes. One woman on Reddit wrote: “Stopped adalimumab at 8 weeks because my OB said ‘better safe than sorry.’ Flared badly by 20 weeks. Ended up on prednisone. Got gestational diabetes. Baby born at 34 weeks.”
Preconception Planning: The 6-Month Rule
You wouldn’t start a marathon without training. Why start a pregnancy without planning?
The best outcomes come from a team: a rheumatologist, a maternal-fetal medicine specialist, and a pharmacist. They meet at least six months before you try to conceive. Here’s what they do:
- Review every medication you’re on.
- Switch unsafe drugs to safer ones-like switching from methotrexate to azathioprine.
- Check your disease activity. Are you in remission? If not, get it there before pregnancy.
- Update your vaccines (flu, whooping cough, COVID-19). Live vaccines? Avoid during pregnancy.
- Start prenatal vitamins with folic acid (at least 0.8 mg daily). This reduces birth defect risk even further.
At Duke’s pregnancy clinic, this kind of planning dropped unsafe medication use at conception from 38.7% down to 8.2%. That’s not luck. That’s planning.
What About Breastfeeding?
Yes, you can breastfeed. And yes, most of your medications are safe.
Biologics like adalimumab, certolizumab, and infliximab barely make it into breast milk. Studies show levels are 0.005% to 0.13% of the mom’s blood concentration. That’s like a drop in an ocean. The American Academy of Pediatrics says these drugs are compatible with breastfeeding.
Hydroxychloroquine? Safe. Azathioprine? Safe. Even corticosteroids? Safe-unless you’re taking more than 20 mg daily, and even then, you can usually keep going with monitoring.
One mom wrote on MyHealthTeams: “Continued hydroxychloroquine throughout pregnancy-baby born at 39 weeks, 7 lbs 10 oz, zero complications. Breastfed for 14 months.”
What About Biosimilars?
Since Humira’s patent expired in January 2023, eight biosimilars have hit the market: Amjevita, Hyrimoz, Hadlima, and others. You might be prescribed one. Should you worry?
No. The FDA says they’re identical in safety and effectiveness to the original. If adalimumab is safe in pregnancy, so is Amjevita. Same drug. Same packaging. Same science.
What’s Still Unknown?
There’s a gap. For newer drugs like vedolizumab or tocilizumab, we only have data from a few hundred pregnancies. That’s not enough. So doctors can’t say “definitely safe”-only “likely safe.”
That’s why the NIH launched a $12.7 million research network in January 2024. They’re tracking 5,000 pregnant women on newer biologics over five years. Results will come in stages, but we’ll know more by 2027.
What Should You Do Right Now?
If you’re thinking about pregnancy:
- Don’t stop your meds on your own. Flares are dangerous.
- Don’t wait until you’re pregnant to ask about safety.
- Find a rheumatologist who works with maternal-fetal specialists. Ask if they’re part of a pregnancy autoimmune clinic.
- Bring a list of every medication, supplement, and over-the-counter pill you take.
- Ask: “What’s my plan? What do I switch? When? How long before I try?”
And if you’re already pregnant and unsure about your meds? Don’t panic. Call your rheumatologist today. You’re not alone. More than 78% of autoimmune diagnoses happen in women of childbearing age. You’re part of a growing community-and we now have the science to support you.
Can I keep taking my biologic during pregnancy?
Yes, most biologics are safe during pregnancy. TNF inhibitors like certolizumab pegol, adalimumab, and etanercept have been studied in over 28,000 pregnancies and show no increase in birth defects. Certolizumab is preferred in the third trimester because it transfers the least to the baby. Always discuss timing with your rheumatologist-some may recommend pausing after 30 weeks.
Is hydroxychloroquine safe for lupus during pregnancy?
Yes, hydroxychloroquine is one of the safest medications for lupus during pregnancy. Studies of over 12,000 pregnancies show no increased risk of birth defects. It also reduces disease flares by 66% and lowers the risk of preterm birth and preeclampsia by half. It’s recommended to continue throughout pregnancy and even while breastfeeding.
Why do I need to stop methotrexate before getting pregnant?
Methotrexate is a powerful drug that can cause serious birth defects, including cleft palate, missing limbs, and skull abnormalities. Studies show a 17.8% risk of major congenital anomalies in pregnancies exposed to methotrexate. You must stop it at least three months before trying to conceive to allow it to fully leave your system. Never stop it without medical supervision.
Can I breastfeed while on autoimmune medication?
Yes, most autoimmune medications are safe during breastfeeding. Biologics like adalimumab and certolizumab transfer in extremely low amounts-often less than 0.1% of the mother’s blood level. Hydroxychloroquine, azathioprine, and low-dose prednisone are also considered safe. Always check with your doctor, but in most cases, breastfeeding is not only possible-it’s encouraged.
What if I got pregnant without planning my meds?
Don’t panic. Call your rheumatologist and OB/GYN immediately. Many medications can be safely continued once pregnancy is confirmed. If you’re on methotrexate or mycophenolate, stop them right away and switch to a safer alternative under medical supervision. The goal is to get your disease under control as quickly as possible. Many women in this situation go on to have healthy pregnancies with proper care.
Jessica Klaar
February 7, 2026 AT 08:55Just read this whole thing and honestly? I wish my rheumatologist had given me this info 2 years ago. I stopped everything when I got pregnant-no plan, no backup-and ended up in the hospital at 28 weeks with a lupus flare. My daughter was born at 32 weeks. She’s fine now, but I carry so much guilt. Hydroxychloroquine was never even discussed. This article is a godsend.
Elan Ricarte
February 9, 2026 AT 02:34Oh for fucks sake, another ‘trust the science’ sermon. Let me guess-you also think 5G causes autism and vaccines are just Big Pharma’s glittery lollipop? The FDA says certolizumab is safe? Cool. Then why did my cousin’s baby have a cleft palate after she stayed on adalimumab? Coincidence? Nah. It’s called ‘hidden toxicity.’ They don’t test for long-term neuro effects. And don’t even get me started on how they ‘forgot’ to mention that TNF inhibitors can cause maternal liver damage. They’re not drugs-they’re Trojan horses.
Jonah Mann
February 10, 2026 AT 07:26Wait wait wait-I just got diagnosed with RA and I’m trying to get preggo, and I’ve been on methotrexate for 3 years… I thought I had to stop 3 months before? But my doc said ‘just taper slowly’… did I mess up?? I’m panicking. Also, is azathioprine like… a pill? Like, can I just take it? Or do I need an IV? I’m so lost. Pls help. I’ve been googling for 4 hours.
Tricia O'Sullivan
February 10, 2026 AT 18:33Thank you for this meticulously researched and clinically grounded piece. It is both reassuring and profoundly informative. The inclusion of EULAR guidelines and the clear demarcation between safe and contraindicated agents represents a significant advancement in patient-centered care. I shall be sharing this with my colleagues in Dublin.
Ken Cooper
February 12, 2026 AT 14:19So… if you’re on a biosimilar like Amjevita… is it *really* the same as Humira? I mean, I’ve seen people say ‘it’s just a copy’… but the FDA says identical? Like… identical identical? Or just ‘close enough’? I’m scared to switch because my current med works great. Also, what’s the deal with certolizumab? Why does it barely get into the baby? Is it magic? Or science? Please explain like I’m 25 and not a pharmacist.
Sam Dickison
February 13, 2026 AT 18:52Let’s cut through the noise: the real issue here isn’t medication safety-it’s access. Most people can’t afford to see a rheumatologist + MFM specialist + pharmacist. Insurance won’t cover it. And if you’re on Medicaid? Good luck getting a referral. This is all great data… but it’s for the privileged few. The rest of us are still being told ‘just stop everything’ by OBs who don’t know the difference between TNF and JAK inhibitors.
Joseph Charles Colin
February 15, 2026 AT 00:41Key point missed: the 6-month preconception window isn’t just about switching meds-it’s about optimizing disease control. Remission ≠ no symptoms. It means no subclinical inflammation, normal CRP/ESR, and stable joint counts. Many patients think ‘I feel fine’ means they’re safe, but autoimmunity is a silent storm. You need labs, not just feelings. Also, folic acid isn’t optional-it’s non-negotiable. 0.8 mg is the minimum. Go 5 mg if you’re on azathioprine. That’s protocol.
John Sonnenberg
February 15, 2026 AT 02:03WHY IS NO ONE TALKING ABOUT THE FACT THAT THEY’RE USING PREGNANT WOMEN AS GUINEA PIGS FOR PHARMA? THEY’RE PUSHING THESE DRUGS LIKE THEY’RE VITAMINS. WHAT ABOUT THE CHILDREN WHO DEVELOP AUTISM LATER? WHAT ABOUT THE ONES WHO GET LEUKEMIA AT AGE 6? NO ONE HAS STUDIED THAT. THEY JUST SAY ‘SAFE’ BECAUSE THEY DON’T WANT TO PAY FOR LONG-TERM STUDIES. I’M NOT TRUSTING THEM. I’M STAYING OFF EVERYTHING. EVEN IF I FLARE. EVEN IF I LOSE THE BABY. I’LL RISK IT.
Randy Harkins
February 16, 2026 AT 17:51This is the kind of info that gives me hope. I’ve been on hydroxychloroquine for 5 years, and I just got pregnant. I cried when I read that it cuts preterm birth risk by half. I’m breastfeeding now, and my baby is 4 months old-no issues. I’m so glad I didn’t listen to the ‘stop everything’ crowd. You’re not alone. You’re doing amazing. Keep going. You’ve got this. 💪❤️
Tori Thenazi
February 16, 2026 AT 20:23Okay, but have you read the 2022 CDC whistleblower report? They buried data showing that 12% of babies born to moms on TNF inhibitors had undiagnosed heart defects at birth. The FDA knew. They just reclassified them as ‘minor anomalies.’ And guess who funded the ‘safe’ studies? AbbVie. The same company that made Humira. Coincidence? Or cover-up? Also-why are biosimilars cheaper? Because they’re made with cheaper ingredients. I read a paper where they used recycled vials. I’m not taking a chance.
Camille Hall
February 17, 2026 AT 01:04My sister had lupus and got pregnant on hydroxychloroquine. Baby was born at 38 weeks, 8 lbs, no issues. She breastfed for 18 months. I’m 30 and trying to conceive next year-this article made me feel like I can actually do this without sacrificing my health. Thank you for writing this. So many of us are scared. You made it feel possible.
Ritteka Goyal
February 17, 2026 AT 18:52India has been doing this right for decades! We have 12 million women with autoimmune diseases and we never stop meds! We use hydroxychloroquine, azathioprine, and even low-dose prednisone during pregnancy. No problems! Our babies are healthy! Why do Americans overthink everything? You have so many doctors, so many tests, so many pills… but you still panic! In India, we trust our doctors. We don’t need 47 drug tables. We just take what works. Also, I gave birth to 3 kids on methotrexate. No birth defects. Maybe it’s genetics? Maybe it’s just… faith? You all need to chill. 😊