What are the recommended management strategies and medication adjustments for a woman with rheumatoid arthritis who is planning to conceive, during pregnancy, and postpartum?

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Last updated: October 28, 2026 • View editorial policy

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Rheumatoid Arthritis Pregnancy Management

Pre-Conception Planning

Women with rheumatoid arthritis planning pregnancy must achieve optimal disease control before conception, discontinue teratogenic medications at least 1-3 months prior, and transition to pregnancy-compatible DMARDs. 1

Disease Activity Optimization

  • Postpone conception until optimal disease control is reached 1
  • Target clinical remission or low disease activity before attempting pregnancy
  • Recent evidence shows women treated with a treat-to-target approach had median time to pregnancy of 91 days versus 251 days in those without this approach 2
  • Women achieving remission had even shorter time to pregnancy (65 days) 2

Medication Adjustments Before Conception

Discontinue these teratogenic medications:

  • Methotrexate: Stop 1-3 months before conception 3
  • Leflunomide: Stop 24 months prior OR check serum metabolite levels and perform cholestyramine washout if detectable 3
  • Mycophenolate/mycophenolic acid: Stop >6 weeks prior to assess disease stability 3
  • Cyclophosphamide: Stop 3 months prior 3

Continue these pregnancy-compatible medications:

  • Hydroxychloroquine: Strongly recommended to continue 1, 3
  • Sulfasalazine: Continue (up to 2g/day) with daily folic acid supplementation 1, 3
  • Azathioprine: Continue (up to 2mg/kg/day) 1, 3
  • Colchicine: Continue (1-2mg/day) 1, 3
  • Cyclosporine/Tacrolimus: Continue at lowest effective dose 1, 3

TNF inhibitors:

  • Certolizumab: Strongly recommended to continue throughout pregnancy (minimal placental transfer) 3
  • Infliximab, etanercept, adalimumab, golimumab: Can continue through conception and pregnancy 3

NSAIDs: Discontinue if difficulty conceiving due to unruptured follicle syndrome 3

During Pregnancy

First and Second Trimesters

Maintain pregnancy-compatible medications to control disease activity:

  • Continue hydroxychloroquine, sulfasalazine, azathioprine, colchicine 1, 3
  • Continue certolizumab throughout pregnancy 3
  • Continue other TNF inhibitors (infliximab, etanercept, adalimumab, golimumab) 3
  • NSAIDs: Can use in first and second trimesters (nonselective preferred over COX-2 inhibitors) 3

Glucocorticoids:

  • Continue low-dose prednisone (≤10mg/day) if needed 3
  • Taper doses >20mg/day by adding pregnancy-compatible glucocorticoid-sparing agents 3

Discontinue at positive pregnancy test:

  • Rituximab, belimumab, anakinra, abatacept, tocilizumab, secukinumab, ustekinumab 3
  • Exception: Rituximab can be used for life-threatening or organ-threatening disease 3

Third Trimester

Critical medication adjustments:

  • Discontinue NSAIDs completely (risk of premature ductus arteriosus closure) 3
  • TNF inhibitors (except certolizumab): May discontinue several half-lives before delivery if disease well-controlled, OR continue through delivery if disease active 3
    • Note: Continuing through delivery results in significant neonatal drug levels but accumulated evidence suggests no adverse effects 3

Monitoring

  • Monitor disease activity throughout pregnancy
  • Laboratory monitoring at least once per trimester 3
  • Adjust medications as needed to maintain disease control

Delivery Planning

Glucocorticoid stress dosing:

  • Do NOT give stress-dose steroids for vaginal delivery 3
  • DO give stress-dose steroids for cesarean delivery 3

Postpartum and Breastfeeding

Encourage breastfeeding while maintaining disease control with compatible medications 1, 3

Breastfeeding-Compatible Medications

Strongly compatible:

  • Hydroxychloroquine 3
  • TNF inhibitors: infliximab, etanercept, adalimumab, golimumab, certolizumab 3
  • Rituximab 3
  • Prednisone <20mg/day 3

Conditionally compatible:

  • NSAIDs (ibuprofen preferred) 3
  • Sulfasalazine 3
  • Colchicine 3
  • Azathioprine 3
  • Cyclosporine, tacrolimus 3
  • Anakinra, belimumab, abatacept, tocilizumab, secukinumab, ustekinumab 3

For prednisone ≥20mg/day: Discard breast milk obtained within 4 hours of medication 3

NOT compatible with breastfeeding:

  • Methotrexate 3
  • Leflunomide 3
  • Mycophenolate 3
  • Cyclophosphamide 3

Neonatal Considerations

  • Infants exposed to biologic medications in utero can receive all recommended vaccinations 3
  • Monitor for disease flare postpartum and adjust medications accordingly

Critical Principles

The risk of untreated maternal disease must be weighed against potential medication risks 1. Untreated RA is associated with:

  • Prolonged time to pregnancy 2
  • Increased adverse pregnancy outcomes 1
  • Higher rates of pregnancy complications 4, 5

Shared decision-making is essential throughout the preconception, pregnancy, and postpartum periods 1. Comprehensive counseling should enable informed decisions and reduce concerns about medication use during these critical periods.

References

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.