Discontinuation of methotrexate is indicated for this patient with rheumatoid arthritis (RA) who is interested in becoming pregnant. This nonbiologic disease-modifying antirheumatic drug is both highly teratogenic and abortifacient and must be discontinued 3 months prior to attempting to conceive. Although this patient is taking folic acid to help reduce her incidence of methotrexate side effects, taking folic acid supplements during pregnancy can reduce the risk of certain neural tube birth defects. Therefore, she should not discontinue folic acid even if she discontinues methotrexate.

Considerable epidemiologic evidence in patients with systemic lupus erythematosus as well as RA supports the use of hydroxychloroquine during pregnancy. The risks to mothers and their fetuses appear low, particularly when balanced against the consequences of discontinuing treatment in anticipation of pregnancy. Greater disease activity during pregnancy is associated with small gestational age and preterm delivery. In addition, patients in whom all medications are stopped, including hydroxychloroquine, run the risk of flare, which can impair their physical functioning and make coping with pregnancy more difficult. No increases in adverse maternal or fetal outcomes have been observed in a number of studies in which hydroxychloroquine has been continued throughout pregnancy.

Low-dose glucocorticoids are frequently used but should be avoided if possible before 14 weeks of gestation because of the risk of cleft palate. Glucocorticoid use can contribute to gestational diabetes and hypertension. However, they can be useful in the management of RA in pregnancy if the benefit of treatment is thought to exceed risk.