USE OF WARFARIN IN PREGNANCY

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(Date of issue: December 2017, Version: 3)

This is a UKTIS monograph for use by health care professionals. For case-specific advice please contact UKTIS on 0344 892 0909. To report an exposure please download and complete a pregnancy reporting form. Please encourage all women to complete an online reporting form.

Summary

Warfarin is a coumarin anticoagulant and vitamin K antagonist which acts by inhibiting clotting factors II, VII, IX and X. It is indicated for: the prevention of systemic embolism in patients with rheumatic heart disease and atrial fibrillation, prophylaxis after insertion of prosthetic heart valves, prophylaxis and treatment of venous thrombosis and pulmonary embolism, and treatment of transient cerebral ischaemic attacks.

Fetal warfarin syndrome (FWS) or warfarin embryopathy, characterised by nasal hypoplasia and skeletal abnormalities, including short limbs and digits, and stippled epiphyses, is a well-recognised complication of first trimester warfarin use in pregnancy. The critical risk period for FWS is thought to span gestational weeks 6-12, but has not been definitively confirmed. The likelihood of warfarin embryopathy following exposure during this critical period has been proposed to be as high as 30%, although more recent studies suggest a risk of 6-10%. There is some evidence that the risk of FWS may be dose-dependent, with doses of >5mg carrying a higher risk, although doses less than this are not without risk.

Exposure that extends beyond or commences after the first trimester of pregnancy has been associated with CNS defects and eye anomalies. Second and third trimester exposure confers a risk of fetal, placental or neonatal haemorrhage.

Postnatal developmental delay has been observed following in utero exposure to warfarin, but when reported was mainly in children with FWS.

Use of warfarin in pregnancy may be associated with an increased incidence of spontaneous abortion and stillbirth; this has also been reported following use of other anticoagulants such as heparin.

Warfarin exposure in pregnancy should be avoided if possible by changing to a non-teratogenic anticoagulant, usually a low molecular weight heparin (LMWH), before pregnancy or as soon as possible after pregnancy is suspected. In some patients with mechanical heart valves the continued use of warfarin may need to be considered where other agents do not provide adequate anticoagulation.

Detailed ultrasound scans should be considered to screen for structural anomalies associated with fetal warfarin syndrome where exposure has occurred during or beyond the first trimester. Other risk factors may also be present in individual cases which may independently increase the risk of adverse pregnancy outcome. Clinicians are reminded of the importance of consideration of such factors when performing case-specific risk assessments.
                      
This document is regularly reviewed and updated. Only use full UKTIS monographs downloaded directly from TOXBASE.org to be sure you are using the most up-to-date version. The summaries of these monographs are openly available on UKTIS.org.

This is a summary of the full UKTIS monograph for health care professionals and should not be used in isolation. The full UKTIS monograph and access to any hyperlinked related documents is available to health care professionals at www.toxbase.org.

If you have a patient with exposure to a drug or chemical and require assistance in making a patient-specific risk assessment, please telephone UKTIS on 0344 892 0909 to discuss the case with a teratology specialist.

If you would like to report a pregnancy to UKTIS please click here to download our pregnancy reporting form. Please encourage all women to complete an online reporting form.

Disclaimer: Every effort has been made to ensure that this monograph was accurate and up-to-date at the time of writing, however it cannot cover every eventuality and the information providers cannot be held responsible for any adverse outcomes of the measures recommended. The final decision regarding which treatment is used for an individual patient remains the clinical responsibility of the prescriber. This material may be freely reproduced for education and not for profit purposes within the UK National Health Service, however no linking to this website or reproduction by or for commercial organisations is permitted without the express written permission of this service. This document is regularly reviewed and updated. Only use UKTIS monographs downloaded directly from TOXBASE.org or UKTIS.org to ensure you are using the most up-to-date version.