Animal studies have shown an increased risk of maternal bleeding during pregnancy but no increase in fetal malformations or fetal or maternal deathsLabel. It is unknown if this animal data also translates to humans so apixaban should only be used in pregnancy if the benefits outweigh the risksLabel. It is not know whether apixaban is safe and effective in labor and during birth, though animal studies have shown an increased rate of maternal bleedingLabel. Animal studies in rats show apixaban excreted in milk, though it is not know if this also applies to humansLabel. Nursing mothers should either stop breastfeeding or stop taking apixaban depending on the risk and benefit of each optionLabel. Studies to determine safety and effectiveness in pediatric patients have yet to be performedLabel. Studies that involved geriatric patients (at least 75 years old) saw no difference in safety or effectiveness compared to younger patients, though geriatric patients at an especially advanced age may be more susceptible to adverse effectsLabel. Dosage adjustments for patients with end stage renal disease(ESRD) are based on estimates of pharmacokinetic principles and not clinical studyLabel. Patients with ESRD may experience pharmacodynamics similar to those seen in well controlled studies but it may not lead to the same clinical effectsLabel. Dosage adjustments are not necessary in mild hepatic impairmentLabel. In moderate hepatic impairment patients may already experience abnormalities in coagulation and so no dose recommendations are possibleLabel. Apixaban is not recommended for patients with severe hepatic impairmentLabel.