As discussed earlier, the incidence of amoebic liver abscess is much less in females. Surprisingly, on going through the literature, we have not come across any publication on "amoebic liver abscess during pregnancy". While viral hepatitis is so common during pregnancy, why is amoebic liver abscess so uncommon? Chaves¹in his analysis of 56 cases of hepatic amoebiasis mentioned one case of a pregnant woman in whom chest X-rays were avoided
The author has treated one case of amoebic liver abscess during the first trimester, two cases during the second trimester and one case each during the last trimester and postpartum period.
The points worth noting in pregnant women having an amoebic liver abscess are discussed below.

Problems during the first trimester of pregnancy

1. The problem of radiation is of maximum concern during this period. Unfortunately, in my patient, X-rays had to be repeated as later, she developed sympathetic pleural effusion requiring aspiration.
2. A liver scan was carried out in my patient as she was found to have false localisation. Theoretically scanning is unsafe in pregnancy because of the risk of radiation to the foetus. But in practice this risk is negligible compared to the risk of fatality to the mother. This has been supported by a recent report describing the details of isotope radiation during pregnancy. (This problem has been discussed in Section IV).
3. Regarding the use of antiamoebic drugs in pregnancy, there is apprehension in the minds of certain authorities, as can be appreciated by the following facts.

1. Metronidazole-One of the Physicians' Handbook² mentions this drug to be contra-indicated in pregnancy, possibly because of its carcinogenicity in rodents. Other authors affirm that though sufficient evidence is not available except in a short high dose regimen, metronidazole can safely be used in pregnancy. Fluker³ speaks of no ill effects to mother or foetus apart from transient disorientation in the mother if given in a dose of 4.2 G stat. Rodin and Hass⁴ consider this drug as being quite safe only in the second and third trimesters.
2. Chloroquine may increase nausea and vomiting in the first trimester of pregnancy. According to Stirrat⁵ this drug is contrauldicated in pregnancy because it can cause retinal and cochlear damage in the foetus.
3. According to many authorities^6-9 emetine should be avoided in pregnancy, because of the risk of cardiotoxicity to the foetus.

In practice, we have used all these drugs. We did advise termination of pregnancy to this patient in the first trimester, specially since she was not keen on continuing with it, even though the risk to the foetus as explained to her was only theoretical.

Amoebic liver abscess in the second trimester
We had two such patients at the time when facilities for scintigraphy were not available at our centre. Besides injection emetine and oral metronidazole therapy, aspiration was done in both the cases. Both recovered and delivered normally at full term. Both infants were pronounced normal by the attending paediatrician.

Problems in the last trimester and the post-partum period
One of my patients was seen by a physician ten days before delivery for symptoms of pain in the right lower chest and fever. He made a diagnosis of either pneumonia or pleurisy at the right base and X-ray chest was ordered. The X-ray chest including the right dome of the diaphragm was normal. I was asked to see the case on the day she delivered. She had been running high fever for ten days and had severe pain in the right hypochondrium and subcostal region. I could palpate a markedly enlarged and tender right lobe of the liver 6 cms. below the costal margin. A liver scan confirmed the clinical diagnosis of inferior surface right lobe amoebic liver abscess which needed aspiration because the patient was in agony. I could appreciate the difficulty the previous physician must have had in palpating the enlarged liver, along with a nine months pregnant uterus. Liver scanning or tapping earlier would have also created problems.
After removal of 300 ml. of chocolate coloured pus and 3 injections each of 60 mgm. of emetine and metronidazole 1.2 G per day for 3 days, the temperature touched normal and the pain subsided. Five days later, on the same treatment, the fever shot upto 39⁰ C. White celI count was elevated again. Secondary infection of the liver abscess was suspected. To my surprise repeat tapping revealed 40 ml. of the same odourless chocolate coloured pus. Urine examination now done revealed evidence of severe urinary infection (she was catheterised during delivery) which responded to antibiotics.
Although the patient received injection emetine 60 mg. daily for 8 days and 1.2 G metronidazole per day for ten days, the new born infant, who was being given breast feeds, was examined thoroughly at the end of ten days and was declared normal by the paediatrician.
According to my experience therefore, the fear of using amoebicidal drugs in pregnancy has been exaggerated by some. In a fatal illness like amoebic liver abscess, one should not risk the mother's life.

References

1. Chaves, F I Z C, Am. J. Gastroent., 1977, 68, 273.
2. Physician's Handbook, 1st edition, Lange Medical Publications, Maruze Asian Edition, Marcus, A, Krupp, et al, 1976, 598.
3. Fluker, J L, Brit. J. Ven. Dis., 1961, 36, 280
4. Rodin, P. and Hass, G. Brit. J. Ven. Dis.,42, 210.
5. Stirrat, G M, Prescribers I., 1973, 13, 135.
6. Turner P P Brit Heart J. 1963, 25, 81
7. Kini, P M, Venugopal, N S. et al, J Ass. Phys. Ind., 1969, 17, 457.
8. Kapadia, R M, J. Ind. Med. Ass., 1964,43, 461.
9. Lister, G D, J. Trop. Med. Hyg., 1968, 71, 219.