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Rheumatology
Prescribing in pregnancy
Quick reference guide
Prednisolone
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Hydroxychloroquine
≤400mg/day
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Methotrexate
≤25mg/week
Periconception
Stop ≥1 month pre-conception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception
Stop ≥1 month pre-conception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Sulfasalazine
with folic acid 5 mg/day in first trimester
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
In the healthy, full-term infant only
Paternal exposure
If conception is delayed by >12months, consider stopping sulfasalazine alongside investigation of other causes of infertility
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
*In the healthy, full-term infant only
Paternal exposure
*If conception is delayed by >12months, consider stopping sulfasalazine alongside investigation of other causes of infertility
Leflunomide
Periconception
*Cholestyramine washout
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception
Cholestyramine washout
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Azathioprine
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Ciclosporin
Periconception
1st Trimester
*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.
2nd/3rd Trimester
*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.
Breastfeeding
Paternal exposure
Periconception
1st Trimester
*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.
2nd/3rd Trimester
*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.
Breastfeeding
*In the healthy, full-term infant only
Paternal exposure
*If conception is delayed by >12months, consider stopping sulfasalazine alongside investigation of other causes of infertility
Tacrolimus
Periconception
1st Trimester
*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.
2nd/3rd Trimester
*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.
Breastfeeding
Paternal exposure
Periconception
1st Trimester
*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.
2nd/3rd Trimester
*Suggested monitoring of maternal blood pressure, renal function, blood glucose and drug levels.
Breastfeeding
*In the healthy, full-term infant only
Paternal exposure
*If conception is delayed by >12months, consider stopping sulfasalazine alongside investigation of other causes of infertility
Cyclophosphamide
Periconception
Only in cases of severe (life or organ-threatening) maternal disease.
1st Trimester
Only in cases of severe (life or organ-threatening) maternal disease.
2nd/3rd Trimester
Only in cases of severe (life or organ-threatening) maternal disease.
Breastfeeding
Paternal exposure
Periconception
Stop ≥1 month pre-conception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Mycophenolate mofetil
Periconception
Stop ≥6 weeks pre-conception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception
Stop ≥6 weeks pre-conception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Intravenous immunoglobulin
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Infliximab
Periconception
1st Trimester
2nd/3rd Trimester
*If low risk of disease flare and stopped by 20 weeks, full-term infant can have a normal vaccination schedule.
Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester
*If low risk of disease flare and stopped by 20 weeks, full-term infant can have a normal vaccination schedule.
Breastfeeding
Paternal exposure
Etanercept
Periconception
1st Trimester
2nd/3rd Trimester
*If low risk of disease flare and stopped by 32 weeks, full-term infant can have a normal vaccination schedule.
Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester
*If low risk of disease flare and stopped by 32 weeks, full-term infant can have a normal vaccination schedule.
Breastfeeding
Paternal exposure
Adalimumab
Periconception
1st Trimester
2nd/3rd Trimester
*If low risk of disease flare and stopped by 28 weeks, full-term infant can have a normal vaccination schedule.
Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester
*If low risk of disease flare and stopped by 28 weeks, full-term infant can have a normal vaccination schedule.
Breastfeeding
Paternal exposure
Certolizumab
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Golimumab
Periconception
1st Trimester
2nd/3rd Trimester
*If low risk of disease flare and stopped by 28 weeks, full-term infant can have a normal vaccination schedule.
Breastfeeding
Paternal exposure
Periconception
1st Trimester
2nd/3rd Trimester
*If low risk of disease flare and stopped by 28 weeks, full-term infant can have a normal vaccination schedule.
Breastfeeding
Paternal exposure
Rituximab
Periconception
Consider stopping at conception.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
1st Trimester
Severe disease if no alternatives.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
2nd/3rd Trimester
Severe disease if no alternatives.
If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.
Breastfeeding
Limited evidence.
Paternal exposure
Limited evidence.
Periconception
Consider stopping at conception.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
1st Trimester
Severe disease if no alternatives.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
2nd/3rd Trimester
Severe disease if no alternatives.
If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.
Breastfeeding
Limited evidence.
Paternal exposure
Limited evidence.
IL-6 inhibitors
Periconception
Consider stopping at conception.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
1st Trimester
Severe disease if no alternatives.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
2nd/3rd Trimester
Severe disease if no alternatives.
If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.
Breastfeeding
Limited evidence.
Paternal exposure
Limited evidence.
Periconception
Consider stopping at conception.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
1st Trimester
Severe disease if no alternatives.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
2nd/3rd Trimester
Severe disease if no alternatives.
If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.
Breastfeeding
Limited evidence.
Paternal exposure
Limited evidence.
IL-1 inhibitors
Periconception
Consider stopping at conception.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
1st Trimester
Severe disease if no alternatives.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
2nd/3rd Trimester
Severe disease if no alternatives.
If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.
Breastfeeding
Limited evidence.
Paternal exposure
Limited evidence.
Periconception
Consider stopping at conception.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
1st Trimester
Severe disease if no alternatives.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
2nd/3rd Trimester
Severe disease if no alternatives.
If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.
Breastfeeding
Limited evidence.
Paternal exposure
Limited evidence.
Abatacept
Periconception
Consider stopping at conception.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
1st Trimester
Severe disease if no alternatives.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
2nd/3rd Trimester
Severe disease if no alternatives.
If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.
Breastfeeding
Limited evidence.
Paternal exposure
Limited evidence.
Periconception
Consider stopping at conception.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
1st Trimester
Severe disease if no alternatives.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
2nd/3rd Trimester
Severe disease if no alternatives.
If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.
Breastfeeding
Limited evidence.
Paternal exposure
Limited evidence.
Belimumab
Periconception
Consider stopping at conception.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
1st Trimester
Severe disease if no alternatives.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
2nd/3rd Trimester
Severe disease if no alternatives.
If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.
Breastfeeding
Limited evidence.
Paternal exposure
Limited evidence.
Periconception
Consider stopping at conception.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
1st Trimester
Severe disease if no alternatives.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
2nd/3rd Trimester
Severe disease if no alternatives.
If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.
Breastfeeding
Limited evidence.
Paternal exposure
Limited evidence.
IL-17 inhibitors
Periconception
Consider stopping at conception.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
1st Trimester
Severe disease if no alternatives.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
2nd/3rd Trimester
Severe disease if no alternatives.
If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.
Breastfeeding
Limited evidence.
Paternal exposure
Limited evidence.
Periconception
Consider stopping at conception.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
1st Trimester
Severe disease if no alternatives.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
2nd/3rd Trimester
Severe disease if no alternatives.
If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.
Breastfeeding
Limited evidence.
Paternal exposure
Limited evidence.
IL-12/23 inhibitors
Periconception
Consider stopping at conception.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
1st Trimester
Severe disease if no alternatives.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
2nd/3rd Trimester
Severe disease if no alternatives.
If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.
Breastfeeding
Limited evidence.
Paternal exposure
Limited evidence.
Periconception
Consider stopping at conception.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
1st Trimester
Severe disease if no alternatives.
May be considered to manage severe maternal disease if no other pregnancy-compatible drugs are suitable.
2nd/3rd Trimester
Severe disease if no alternatives.
If used in third trimester, avoid live vaccinations in infant vaccination schedule until 6 months of age.
Breastfeeding
Limited evidence.
Paternal exposure
Limited evidence.
JAK-inhibitors
Periconception
Stop ≥2 weeks pre-conception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Limited evidence.
Periconception
Stop ≥2 weeks pre-conception
1st Trimester
2nd/3rd Trimester
Breastfeeding
Paternal exposure
Limited evidence.
Considerations
The tool is for educational use only, is not meant to be a substitute for professional advice and should not be used for medical diagnosis and/or medical treatment.
References
Russell MD, Dey M, Flint J, Davie P, Allen A, Crossley A, Frishman M, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Schreiber K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I; BSR Standards, Audit and Guidelines Working Group. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford). 2022 Nov 2:keac551. doi: 10.1093/rheumatology/keac551. Epub ahead of print. Erratum in: Rheumatology (Oxford). 2022 Dec 13;: PMID: 36318966
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