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Coumadin : Pregnancy
Coumadin® is a safe drug when administered and monitored properly. Indeed, oral anticoagulation is a vital treatment for certain conditions, such as those listed on the Indications page of his symposium. However, one of the drawbacks for Coumadin® is the potential for birth defects and/or hemorrhage in the offspring of mothers taking the drug. There is apparently a link between some birth defects and Coumadin® taken by the mother during early pregnancy [Becker 1975, Carson 1976, Hall 1965, Holzgreve 1976, Pettifor 1975, Shaul 1975, Shaul 1977, Sherman 1976, Warkany 1975, Warkany 1976]. The actual degree (or percentage) of risk to the unborn child is not known. In most circumstances, Coumadin® should be avoided in women of child bearing age unless there is absolutely no other option. If at all possible, another anticoagulant regimen should be used.
However, there are situations in women of child-bearing age where Coumadin® is still the mainstay of therapy, such as recurrent pulmonary emboli. If a young woman needs to start Coumadin® during the child-bearing years, it is very important to educate the patient on the potential harm to the unborn child and establish an effective birth control plan. Before starting therapy, female patients should be asked about their intent to bear children in the future, their birth control methods at present, and their religious beliefs. For the woman who is not planning or desiring further children, sterilization by tubal ligation or hysterectomy would be the most reliable preventative step. In younger women anticipating a new or enlarging family, Coumadin® should not be prescribed if any other possible choice can be used. For some patients, this might mean daily shots with heparin, another anticoagulant medication which cannot be given by mouth. If Coumadin® is still required for clinical reasons, then birth control intervention must be prescribed as well. A longer acting form of birth control such as an IUD or Norplant® are probably best, since daily birth control pills could be accidently or purposefully discontinued, risking an unwanted or unexpected pregnancy while taking Coumadin®. Educational services like Planned Parenthood can assist in selecting birth control methods that are acceptable to the patient and their lifestyle and/or values. Prevention is far better than dealing with the consequences after a pregnancy has occurred.
Occasionally a women is diagnosed with heart or vascular problems during pregnancy. The most common form of heart problem discovered during pregnancy is mitral stenosis (from prior rheumatic fever). Some of these mothers will not survive delivery if the heart disease is left untreated. Intervention may, in some cases, require heart valve surgery even during the later half of the pregnancy. Fortunately, the fetus tolerates heart surgery remarkably well and spontaneous loss of the pregnancy is rare. If at all possible, a "tissue" heart valve design should be used in this setting. Nearly all of these valves can be used without the need for Coumadin®. However, if anticoagulation is required during pregnancy for any reason, it is best to administer heparin instead of Coumadin® . Heparin cannot be given by mouth, and must be administered by shots under the skin three times per day, or by continuous intravenous infusion. Some pregnant mothers with heart problems or clotting problems will be placed on heparin shots for many months before the birth of their child. Fortunately, there is no known association between heparin and birth defects.
- Becker MH, Genieser NB, Finegold M, Miranda D, Spackman T. Chondrodysplasia punctata. Is maternal warfarin therapy a factor? Am. J. Dis. Child. 129:356-359, 1975.
- Carson M, Reid M. Warfarin and fetal abnormality . Lancet 1:1127, 1976.
- Hall JG. Embryopathy associated with oral anticoagulant therapy. Birth Defects 12:33, 1965.
- Holzgreve W. Carey JC, Hall BD. Warfarin-induced fetal abnormalities. Lancet 2: 914, 1976.
- Pettifor JM, Benson R. Congenital malformations associated with the administration of oral anticoagulants during pregnancy. J Pediatr 86:459, 1975.
- Shaul WL, Emery H, Hall JG. Chondrodysplasia punctata and maternal warfarin use during pregnancy. Am. J. Dis. Child. 129:360-362, 1975.
- Shaul WL, Hajj JG. Multiple congenital anomalies associated with oral anticoagulants. Am J Obstet Gynecol 137:191, 1977.
- Sherman S, Hall BD. Warfarin and fetal abnormality. Lancet 1: 692, 1976.
- Warkany J. A warfarin embryopathy? Am. J. Dis. Child. 129:287-288, 1975.
- Warkany J. Warfarin embryopathy. Teratology 14:205, 1976.
Additional Coumadin Sections:
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