Hydroxychloroquine is NOT Contraindicated in Pregnancy
Hydroxychloroquine should be continued throughout pregnancy and is strongly recommended for pregnant women with systemic lupus erythematosus and other rheumatic diseases. 1
Guideline Recommendations
Multiple major rheumatology societies explicitly recommend HCQ use during pregnancy:
The 2020 American College of Rheumatology strongly recommends continuing HCQ 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
The 2025 EULAR guidelines list hydroxychloroquine as a pregnancy-compatible antirheumatic drug that should be continued for maintenance of remission or treatment of disease flares. 1
The 2024 KDIGO guidelines for lupus nephritis recommend HCQ be continued during pregnancy to reduce the risk of pregnancy complications, explicitly stating it should be started before 16 weeks of gestation. 1
Maternal and Fetal Benefits
HCQ provides substantial benefits during pregnancy that outweigh any theoretical risks:
Reduces lupus disease flares during pregnancy, with cessation of HCQ associated with significantly increased disease activity and flare rates. 1, 2
Decreases rates of preterm birth and intrauterine growth retardation in pregnant women with SLE. 1
Allows for lower corticosteroid doses during pregnancy, reducing steroid-related complications. 2
May reduce risk of preeclampsia when combined with low-dose aspirin. 1
Safety Profile
The evidence overwhelmingly supports HCQ safety in pregnancy:
The FDA drug label states that prolonged clinical experience and published epidemiologic studies have not identified a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. 3
HCQ readily crosses the placenta, but no retinal toxicity, ototoxicity, cardiotoxicity, or growth and developmental abnormalities have been observed in children exposed in utero. 3, 4
A study of 133 pregnancies with HCQ exposure found no difference in pregnancy outcomes, malformations, or developmental abnormalities compared to controls, with mean follow-up of 26 months showing normal development. 4
Prospective data from 56 pregnancies with continuous HCQ use showed no increased rates of miscarriage, stillbirth, or congenital abnormalities. 2
Dosing Considerations
Standard dosing does not require adjustment during pregnancy, as pharmacokinetic studies show that while volume of distribution increases, clearance and 24-hour area under the curve remain unchanged. 5
Typical doses are 200-400 mg daily (hydroxychloroquine sulfate), which have been extensively studied and found safe. 1, 4
Critical Contraindications
The only true contraindications to HCQ in pregnancy are:
- Known allergy to hydroxychloroquine or chloroquine 1
- Severe adverse effects or intolerance 1
- G6PD deficiency (relative contraindication due to hemolysis risk, though recent data suggest lower risk than previously thought) 1
Common Pitfall to Avoid
Do not discontinue HCQ when a patient becomes pregnant or is planning pregnancy. Stopping HCQ precipitates disease flares and increases maternal morbidity without providing any fetal benefit. 1, 2 The evidence shows that cessation of HCQ during pregnancy significantly increases lupus activity, requiring higher corticosteroid doses and exposing both mother and fetus to greater risks. 2
Breastfeeding Compatibility
HCQ is safe during breastfeeding, as it is present in breast milk at low levels with no adverse effects reported in breastfed infants. 3 No retinal, ototoxic, cardiotoxic, or developmental abnormalities have been observed in children exposed through breastmilk. 3