Hydroxychloroquine (HCQ) is a medication used to manage chronic autoimmune diseases. The decision to continue or stop HCQ upon becoming pregnant requires immediate consultation with medical specialists, including a rheumatologist and an obstetrician specializing in Maternal-Fetal Medicine. Current medical consensus strongly supports the continuation of HCQ throughout pregnancy in most cases due to its established safety profile and the significant risks associated with uncontrolled maternal disease.
Primary Conditions Treated by Hydroxychloroquine
Hydroxychloroquine is a disease-modifying anti-rheumatic drug (DMARD) that possesses immunomodulatory and anti-inflammatory properties. Its mechanism involves slowing the overactive immune response characteristic of autoimmune conditions. The drug is a foundational treatment for systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA).
For individuals with SLE, HCQ helps prevent disease flares, which are periods of increased disease activity that can damage vital organs like the kidneys and heart. It also manages the inflammatory symptoms of rheumatoid arthritis, protecting joints from progressive damage. HCQ is sometimes used for refractory antiphospholipid syndrome due to its anti-thrombotic activity.
Hydroxychloroquine Safety Profile for the Fetus
Research consistently reinforces the safety of HCQ use throughout pregnancy. Studies indicate that exposure to HCQ during the first trimester does not increase the background risk of major congenital malformations, which is approximately 3% to 5% in the general population. This is important because the first trimester is the period of organogenesis when the fetus is most susceptible to drug-induced structural defects.
Concerns about potential fetal toxicity, such as retinal or cardiac issues, have not been substantiated in infants exposed prenatally. The drug is not associated with an increased incidence of low birth weight or preterm delivery. In fact, its use has been linked to a decreased risk of these adverse outcomes in mothers with systemic lupus. HCQ has even been shown to increase mean fetal birth weight and reduce the incidence of high lupus activity during pregnancy. Furthermore, in pregnancies at increased risk for congenital heart block associated with maternal anti-Ro/La antibodies, HCQ might offer a protective effect, reducing the chance of this rhythm problem in the fetus.
Risks of Untreated Maternal Autoimmune Disease
Uncontrolled autoimmune disease activity during pregnancy poses substantial risks. A flare-up of conditions like SLE or RA can have severe consequences for both the mother and the developing fetus. Uncontrolled maternal disease significantly increases the risk of hypertensive disorders, notably preeclampsia, which involves high blood pressure and potential organ damage.
The fetus is also at heightened risk from active maternal disease, which can lead to premature birth and intrauterine growth restriction (IUGR). Severe flares, particularly those involving kidney inflammation (lupus nephritis), increase the likelihood of spontaneous abortion, stillbirth, and maternal organ failure. Maintaining disease quiescence with medications like HCQ is considered a preventative measure against these complications.
Medical Monitoring and Treatment Protocols
Management of a pregnancy involving HCQ requires a collaborative, multidisciplinary medical team. This team should include a Maternal-Fetal Medicine specialist, the treating rheumatologist, and the general obstetrician.
Maternal monitoring protocols include routine blood and urine testing to check for signs of disease activity or the onset of preeclampsia. The mother also requires baseline and periodic ophthalmologic exams to monitor for retinal toxicity, a potential long-term side effect. For the fetus, specialized monitoring may be necessary for mothers who test positive for anti-Ro or anti-La antibodies, which may require fetal echocardiograms to assess the cardiac conduction system. The prescribed HCQ dose must be maintained throughout the pregnancy, and the individual should never self-adjust or discontinue the medication without explicit medical guidance.