When you have an autoimmune disease and are thinking about having a baby, the biggest question isn’t just can I get pregnant-it’s can I stay healthy while keeping my baby safe. For years, the default advice was to stop all medications before conception. But that’s no longer the truth. Today, we know that poorly controlled disease is far more dangerous than most medications used to treat it.
Why Preconception Planning Matters More Than You Think
Most autoimmune diseases-like lupus, rheumatoid arthritis, and psoriatic arthritis-hit women during their childbearing years. About 78% of diagnoses happen between ages 15 and 44. And here’s the hard part: if your disease flares during pregnancy, your risks go up sharply. You’re 3 to 5 times more likely to develop preeclampsia. Your baby is nearly 3 times more likely to be born too early. That’s why waiting until you’re already pregnant to figure out your meds is like trying to fix a leaky roof during a storm. The best time to plan is at least six months before you start trying. This gives your body time to adjust, your medications time to clear, and your doctors time to switch you to safer options if needed. Many women don’t realize this until they’re already pregnant-and by then, it’s too late to undo risky choices.Medications That Are Safe to Keep Taking
You don’t have to give up your treatment to have a healthy pregnancy. In fact, continuing the right meds lowers your risk of complications. Here’s what the latest science says:- Hydroxychloroquine (Plaquenil): Used for lupus and rheumatoid arthritis, it’s safe in over 98% of pregnancies. It doesn’t cause birth defects-and it actually cuts your risk of flares by two-thirds and reduces preterm birth by half.
- Azathioprine: Safe in 95% of cases. Studies show only 2.1% of babies born to moms on this drug are premature, compared to 8.7% when lupus is active.
- Sulfasalazine: No signs of harm in over 3,200 pregnancies. It’s a go-to for inflammatory bowel disease and arthritis.
- TNF inhibitors (like adalimumab, etanercept, certolizumab): Collectively safe in 95% of pregnancies. But there’s a key difference: certolizumab pegol barely crosses the placenta-just 0.2% of the mom’s blood level reaches the baby. That makes it the top choice for third-trimester use.
- Corticosteroids (like prednisone): Used carefully, they’re acceptable. High doses long-term can raise blood sugar and blood pressure, but low doses (under 10mg daily) are generally fine.
Medications You Must Stop Before Pregnancy
Some drugs are outright dangerous during pregnancy. If you’re on one of these, switching early isn’t optional-it’s life-saving.- Methotrexate: This one’s a hard stop. It’s linked to a 17.8% risk of serious birth defects-like missing limbs, cleft palate, and brain malformations. You need to stop it at least three months before trying to conceive.
- Mycophenolate mofetil (CellCept): Even worse. It causes facial, ear, and eye defects in nearly 1 in 4 pregnancies. The FDA added a black box warning in 2023. You must stop it at least six weeks before conception, but many doctors recommend 3 months to be safe.
- JAK inhibitors (like tofacitinib, upadacitinib): Most guidelines say avoid them entirely during pregnancy. Japan’s data is promising (only 1.8% birth defect rate in 47 cases), but global experts still recommend switching due to lack of large-scale safety data.
What About Biosimilars and Newer Drugs?
Since Humira’s patent expired in early 2023, eight biosimilars like Amjevita and Hyrimoz hit the market. Good news: they’re just as safe as the original during pregnancy. The FDA confirms they have identical biological effects, so switching to a biosimilar won’t change your risk profile. But what about newer biologics like tocilizumab or vedolizumab? Here’s the problem: there are fewer than 200 documented pregnancies for each. That’s not enough to say they’re 100% safe. Some doctors will still prescribe them if your disease is severe and other options have failed-but only after detailed counseling.What Happens After 32 Weeks? Should You Stop Your Meds?
A lot of OBs still tell women to stop TNF inhibitors at 32 weeks, fearing infection in the newborn. But that advice is outdated. A major study of over 14,000 babies exposed to TNF inhibitors past 32 weeks showed no difference in infection rates compared to unexposed babies. The rate was 7.3% vs. 7.1%. There’s zero evidence to support stopping early. The real rule? With certolizumab, you can keep going right up to delivery. With adalimumab or infliximab, you might pause around 30 weeks just because they cross the placenta more-so the baby doesn’t have too much drug in its system at birth. But even then, it’s not a hard stop. It’s a discussion with your rheumatologist.
What About Breastfeeding?
Yes, you can breastfeed while on most autoimmune meds. Over 98% of biologics don’t transfer meaningfully into breastmilk. In fact, adalimumab levels in milk are so low-0.005% to 0.13% of your blood concentration-that they’re considered negligible. Your baby gets more medicine from your skin cream than from your milk. Hydroxychloroquine, azathioprine, sulfasalazine-all safe during breastfeeding. Even certolizumab, with its tiny placental transfer, is considered safe for nursing. The key is to avoid methotrexate and mycophenolate, which are not safe even after birth.Real Stories: What Works and What Doesn’t
One woman on Reddit shared: “Continued hydroxychloroquine throughout pregnancy-baby born at 39 weeks, 7 lbs 10 oz, zero complications.” Another said: “Stopped adalimumab at 8 weeks because my OB said it was risky. Flared badly at 20 weeks. Ended up on 20mg prednisone daily. Got gestational diabetes. Baby came at 34 weeks.” That’s the difference between following updated guidelines and sticking to old habits. Women who get preconception counseling from both a rheumatologist and a maternal-fetal medicine specialist are 53% less likely to stop meds on their own-and 37% more likely to have a full-term baby.The Bottom Line: You Can Have a Healthy Pregnancy
You don’t have to choose between being healthy and having a baby. The idea that autoimmune meds are automatically dangerous during pregnancy is a myth. The real danger is uncontrolled disease. Start planning early. Talk to your rheumatologist before you stop birth control. Bring a list of your meds. Ask: “Which ones are safe? Which ones do I need to switch? When should I start?” Don’t wait for your OB to tell you what to do-they might not know the latest rheumatology guidelines. The data is clear: with the right plan, 9 out of 10 women with autoimmune diseases can have healthy pregnancies and healthy babies. You’re not alone. Thousands have done it. You can too.Can I stay on my autoimmune medication while pregnant?
Yes, many autoimmune medications are safe during pregnancy. Hydroxychloroquine, azathioprine, sulfasalazine, and certain TNF inhibitors like certolizumab pegol have strong safety data across thousands of pregnancies. The key is to plan ahead and switch out high-risk drugs like methotrexate and mycophenolate before conception.
When should I stop methotrexate before getting pregnant?
You must stop methotrexate at least three months before trying to conceive. It’s a potent drug that can cause serious birth defects, including limb and facial abnormalities. Waiting the full three months allows your body to clear it completely. Don’t rely on your OB’s advice-confirm this with your rheumatologist.
Is it safe to breastfeed while on biologics like adalimumab?
Yes. Biologics like adalimumab, etanercept, and certolizumab transfer in extremely low amounts into breastmilk-often less than 0.1% of your blood level. Studies show no increased risk of infection or side effects in breastfed babies. The benefits of breastfeeding far outweigh any theoretical risk.
What if I get pregnant unexpectedly while on a risky medication?
Don’t panic. Contact your rheumatologist and OB immediately. The risk depends on the drug and how far along you are. For example, if you’re on mycophenolate and just found out you’re pregnant, stopping it now can still reduce harm. Ultrasounds and genetic screening can help monitor fetal development. Many women in this situation go on to have healthy babies with close monitoring.
Do I need to see a specialist before getting pregnant?
Yes. A rheumatologist who specializes in pregnancy and a maternal-fetal medicine specialist should be part of your care team before conception. Studies show women who get this coordinated care are far less likely to stop medications on their own and more likely to carry to term. This isn’t optional-it’s the standard of care for autoimmune patients planning pregnancy.
Are newer drugs like JAK inhibitors safe during pregnancy?
Most international guidelines, including EULAR and ACOG, recommend avoiding JAK inhibitors like upadacitinib during pregnancy due to limited safety data. While Japan’s early data shows a low birth defect rate (1.8%), the global evidence base is too small to confirm safety. If you’re on one and planning pregnancy, switch to a better-studied alternative at least 3-6 months before conception.
Can I get pregnant if my autoimmune disease is active?
It’s possible, but not ideal. Active disease increases risks of miscarriage, preeclampsia, preterm birth, and low birth weight. Experts recommend waiting until your disease is in remission or well-controlled for at least 3-6 months before trying to conceive. This gives you the best chance of a healthy pregnancy.
Will my baby inherit my autoimmune disease?
Autoimmune diseases aren’t directly inherited like genetic disorders. But having a parent with lupus, RA, or another autoimmune condition does slightly increase your child’s lifetime risk-usually to around 5-10%, compared to 1-3% in the general population. It’s not guaranteed, and environmental triggers play a big role. Your baby won’t be born with the disease, but they may have a higher susceptibility later in life.
So let me get this straight - we’re now telling women to stay on meds that used to be considered baby-killers, and the real danger is… not taking them? Wild. I’m glad science caught up with reality. My rheum doc told me to keep hydroxychloroquine during my pregnancy and I didn’t even tell my OB until week 12. She nearly had a heart attack. Turns out she was working off a 2008 pamphlet. 🤷♀️