Hydroxychloroquine Use in Pregnancy

Guideline Recommendations

The American College of Rheumatology strongly recommends continuing hydroxychloroquine during pregnancy if a patient is already taking it, and conditionally recommends starting it if not already prescribed, unless contraindicated by allergy or intolerance 1, 2, 3
The EULAR guidelines list hydroxychloroquine as a pregnancy-compatible antirheumatic drug that should be continued for maintenance of remission or treatment of disease flares 4
The KDIGO guidelines for lupus nephritis recommend hydroxychloroquine be continued during pregnancy to reduce the risk of pregnancy complications, explicitly stating it should be started before 16 weeks of gestation 5, 6

Hydroxychloroquine reduces lupus disease flares during pregnancy, with cessation of hydroxychloroquine associated with significantly increased disease activity and flare rates 5
Hydroxychloroquine decreases rates of preterm birth and intrauterine growth retardation in pregnant women with systemic lupus erythematosus 5
Hydroxychloroquine may reduce risk of preeclampsia when combined with low-dose aspirin 5, 1

Typical doses of hydroxychloroquine are 200-400 mg daily, which have been extensively studied and found safe 4

Known allergy to hydroxychloroquine or chloroquine is a contraindication to its use in pregnancy 1, 2, 3
Severe adverse effects or intolerance to hydroxychloroquine are contraindications to its use in pregnancy 1, 2, 3
G6PD deficiency is a relative contraindication to hydroxychloroquine use due to hemolysis risk, though recent data suggest lower risk than previously thought 6

Discontinuing hydroxychloroquine when a patient becomes pregnant or is planning pregnancy can precipitate disease flares and increase maternal morbidity without providing any fetal benefit 5

The KDIGO 2024 guidelines explicitly state that hydroxychloroquine should be continued during pregnancy to reduce the risk of pregnancy complications 7
Low-dose aspirin (81-100 mg daily) should be started before 16 weeks of gestation and continued until delivery to reduce the risk of preeclampsia and intrauterine growth retardation in women with systemic lupus erythematosus 7

Hydroxychloroquine decreases rates of preterm birth and intrauterine growth retardation in pregnant women with systemic lupus erythematosus 7
When combined with low-dose aspirin, HCQ may reduce the risk of preeclampsia in women with systemic lupus erythematosus 7

Hydroxychloroquine has limited transfer into breast milk and is considered safe with breastfeeding 7

Patients with active lupus nephritis should be counseled to avoid pregnancy while disease is active or when treatment with potentially teratogenic drugs is ongoing, and for at least 6 months after disease becomes inactive 7
Active rheumatic disease during pregnancy increases the risk of adverse pregnancy outcomes including preterm delivery, low birth weight, spontaneous abortion, fetal death, preeclampsia, and intrauterine growth restriction 7