Anticoagulation is contraindicated in any localised or general physical condition or personal circumstance in which the hazard of haemorrhage might be greater than the potential clinical benefits of anticoagulation: Haemorrhagic tendencies or blood dyscrasias; Recent or contemplated surgery of the central nervous system, the eye, and traumatic surgery resulting in large open surfaces; Bleeding tendencies associated with active ulceration or overt bleeding of the gastrointestinal, genitourinary or respiratory tracts; cerebrovascular haemorrhage; aneurysms (cerebral, dissecting aorta); pericarditis and pericardial effusions; bacterial endocarditis; Threatened abortion, eclampsia and preeclampsia. Inadequate laboratory facilities. Unsupervised patients with senility, alcoholism, or psychosis or other lack of patient cooperation; Spinal puncture and other diagnostic or therapeutic procedures with a potential for uncontrollable bleeding; Miscellaneous: Major regional, lumbar block anaesthesia, malignant hypertension and known hypersensitivity to warfarin or to any of the components of Apo-Warfarin.
Use in pregnancy: Apo-Warfarin is contraindicated in women who are or may become pregnant because the drug passes through the placental barrier and may cause fatal haemorrhage to the fetus in utero. Furthermore, there have been reports of birth malformations in children born to mothers who have been treated with warfarin during pregnancy.
Embryopathy characterized by nasal hypoplasia with or without stippled epiphyses (chondrodysplasia punctata) has been reported in pregnant women exposed to warfarin during the 1st trimester. Central nervous system abnormalities also have been reported, including dorsal midline dysplasia characterized by agenesis of the corpus callosum, Dandy-Walker malformation and midline cerebellar atrophy. Ventral midline dysplasia, characterized by optic atrophy and eye abnormalities have been observed. Mental retardation, blindness and other central nervous system abnormalities have been reported in association with 2nd and 3rd trimester exposure. Although rare, teratogenic reports following in utero exposure to warfarin include urinary tract anomalies eg, single kidney, asplenia, anencephaly, spina bifida, cranial nerve palsy, hydrocephalus, cardiac defects and congenital heart disease, polydactyly, deformities of toes, diaphragmatic hernia and corneal leukoma, cleft palate, cleft lip, schizencephaly and microcephaly.
Spontaneous abortion and stillbirth are known to occur and a higher risk of fetal mortality is associated with the use of warfarin. Low birth weight and growth retardation have also been reported.
Women of childbearing potential who are candidates for anticoagulant therapy should be carefully evaluated and the indications critically reviewed with the patient. If the patient becomes pregnant while taking Apo-Warfarin, she should be apprised of the potential risks to the fetus, and the possibility of termination of the pregnancy should be discussed in light of those risks.