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Drug Mechanism Placenta Adverse effects Pre pregnancy recommendation Use in pregnancy Corticosteroids87 Decreases inflammation Exerts effect through genomic mechanisms by binding to DNA Prednisolone 90% inactivated by placental 11-ß hydroxylase (10% crosses placenta) Dexamethasone crosses placenta Fetal adrenal suppression Congenital cataracts Fetal immunosuppression for 15 weeks postpartum Neonatal CMV infection Preterm delivery if dose >20 mg during late pregnancy Maternal hypertension and gestational diabetes No need to discontinue May continue during pregnancy Azathioprine (Imuran)87 Purine Analog Crosses placenta but fetus is unable to metabolize to active form IUGR Bone marrow suppression in fetus Immunosuppression in fetus No need to discontinue May continue during pregnancy Dose should not exceed 1.5–2 mg/kg/day Cyclosporine87 Inhibits DNA transcription Crosses placenta Preterm birth Low birth weight No increase in birth defects No need to discontinue May continue during pregnancy Hydroxycholorquine82,87,88 Accumulates in melatonin containing structure in fetus (uveal tract and inner ear) Crosses placenta No increase in birth defects No retinal or ototoxicity in fetus Long elimination half life but no need to discontinue May continue during pregnancy Sulfasalazine (Azulfadine)87 Dihydrofolate reductase inhibitor Crosses placenta No birth defects No IUGR No need to discontinue May continue during pregnancy Maternal dose should not exceed 2 g Intravenous immunoglobulin89 Decrease antibody mediated disease No adequate studies in women but most likely IgG fraction crosses placenta No definite adverse fetal effects related to drug No need to discontinue Relatively safe to use in pregnancy Useful for antiphospholipid antibody syndrome TNF- antagonists (infliximab or Remicade, etanercept or Enbrel, adalimumab or Humira)87 Biologic agent: binds soluble TNF- No adequate studies in women No birth defects Not teratogenic Short half life Can be discontinued after the first missed menstrual period Discontinue after first missed period Unclear if can continue during pregnancy Cyclophosphamide (Cytoxan)87,90 Alkylating agent Crosses placenta Teratogen: causes birth defects if given in first trimester IUGR Developmental delay in childhood IUFD/stillbirth Stop prior to conception Contraindicated Leflunomide (Arava)87 Pyrimidine synthesis inhibitor Crosses placenta Congenital malformations Long half-life Must be removed with cholestyramine or active charcoal and pregnancy attempted only when active plasma metabolite <0.02 mg/dl Contraindicated Discontinue 9 months prior to conception Methotrexate (Rheumatrex)87 Folic acid antagonist Crosses placenta Miscarriages Congenital anomalies Remains in tissue for 2 months after stopping Contraindicated Stop 3 months prior to conception Mycophenolate mofetil (Cellcept)87 Inhibits purine synthesis Crosses placenta Causes miscarriages Causes birth defects Withdraw prior to conception Contraindicated CMV, cytomegalovirus; IUFD, intrauterine fetal demise; IUGR, intrauterine growth restriction; TNF-, tumor necrosis factor-alpha

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