Hydroxychloroquine (HCQ) is primarily used to treat autoimmune conditions such as Systemic Lupus Erythematosus (SLE) and Rheumatoid Arthritis (RA). For women with these chronic diseases, pregnancy requires balancing the need for disease control against potential risks to the developing fetus. Disease control prevents serious pregnancy complications, making the decision complex. The current medical consensus supports continuing HCQ throughout pregnancy for many patients.
Why Hydroxychloroquine Treatment Must Continue
Maintaining HCQ treatment is fundamental for managing autoimmune disease during pregnancy. Uncontrolled underlying conditions, particularly SLE, pose a far greater risk to both the mother and the fetus. Active maternal disease increases the risk of severe obstetric complications, including preeclampsia, preterm birth, and intrauterine growth restriction.
Stopping HCQ abruptly often causes a flare, which can be devastating during pregnancy. Studies show that women with lupus who discontinue the medication have significantly higher rates of disease flares. Flares may necessitate using more potent immunosuppressive medications, such as high-dose corticosteroids, which carry greater risks than HCQ.
Continuing HCQ also mitigates specific risks to the fetus. In women with anti-Ro/SSA antibodies, HCQ may reduce the chance of the fetus developing neonatal lupus. This condition can manifest as congenital heart block, a serious heart rhythm abnormality. Continuing treatment actively protects the pregnancy from the dangers of uncontrolled systemic inflammation.
Fetal Safety Data and Risk Assessment
Current medical literature largely supports the safety of HCQ use throughout all trimesters of pregnancy. The medication has been used for decades, providing a substantial body of observational data on pregnancy outcomes. Major medical organizations, including the American College of Rheumatology, recommend that women with SLE and RA continue or start HCQ before and during pregnancy.
Concerns regarding fetal exposure involve congenital malformations and potential ophthalmological or auditory toxicity. Extensive systematic reviews and meta-analyses have found no statistically significant increase in the overall risk of major congenital malformations, spontaneous abortions, or fetal death. The rate of birth defects in HCQ-exposed pregnancies is within the 3–5% background risk seen in the general population.
Some larger cohort studies have suggested a small increase in the relative risk of major malformations, particularly with daily doses of 400 mg or more in the first trimester. However, this finding is not universally agreed upon. The benefit of controlling the maternal disease outweighs this potential risk. Studies on infants exposed in utero have not found an increased risk of retinal toxicity or hearing abnormalities, which are known risks associated with long-term maternal use.
Managing Maternal Health During Treatment
For the mother continuing HCQ, managing underlying disease activity is the primary focus of care. Pregnancy can sometimes improve autoimmune symptoms, but it can also trigger a flare, requiring close monitoring. Healthcare providers must distinguish between normal pregnancy symptoms, such as fatigue or joint pain, and genuine disease activity that requires intervention.
Although HCQ is well-tolerated, potential side effects can sometimes be heightened during pregnancy. Gastrointestinal issues, such as nausea or stomach upset, may be more pronounced alongside morning sickness. These symptoms are managed with supportive care or minor adjustments, as stopping the medication is not recommended.
A separate, ongoing requirement for the mother is regular ophthalmological screening, which is a standard precaution for long-term HCQ use. This monitoring detects signs of drug-related retinal toxicity, which depends on cumulative dose and treatment duration. High-risk patients, such as those with pre-existing retinal issues or kidney impairment, may require earlier or more frequent retinal checks.
Collaborative Care and Monitoring Protocols
Successful management of pregnancy while on HCQ relies on a coordinated, multidisciplinary care team. This team must include a rheumatologist, who manages the autoimmune disease, and an obstetrician, often a Maternal-Fetal Medicine (MFM) specialist, who handles high-risk pregnancy aspects. Regular communication between these specialists is essential for aligning treatment decisions with maternal and fetal well-being.
Specific monitoring protocols track the health of both the mother and the fetus. The mother’s disease activity is monitored through regular bloodwork, checking inflammatory markers and autoantibody levels. Fetal surveillance involves specialized ultrasounds, including frequent growth scans, starting in the second trimester. This looks for signs of fetal growth restriction, a known risk of uncontrolled autoimmune disease.
The dosage of hydroxychloroquine generally remains stable throughout the pregnancy, with 200–400 mg daily being the typical recommended range. There is usually no need for dose adjustments based on gestational age or weight gain. Postpartum planning involves the collaborative team, as HCQ is safe during breastfeeding and should be continued to prevent postpartum disease flares.