Sigmoid volvulus after medical management with subsequent operative laparoscopy of unruptured ectopic pregnancy

The use of methotrexate (MTX) as a first-line treatment of ectopic pregnancies has become popular recently. This report details a previously unreported complication of MTX treatment. Presumptive ectopic pregnancy with an initial beta-hCG level of 3,500 mIU/ml was treated with a single intramuscular dose of 50 mg/m2 MTX. Three weeks later with a beta-hCG level of 870 mIU/ml, the patient was operated for suspected rupture of ectopic pregnancy. Laparotomy revealed left aborted tubal pregnancy with active bleeding from left fimbria and estimated 2,000 ml of blood in the cul-de-sac. Left salpingectomy was performed. Two days later the patient developed signs of large bowel obstruction. The second laparotomy revealed sigmoid volvulus, that was treated with detorsion of the sigmoid loop. Although generally safe and effective, MTX should be used with utmost care in treatment of ectopic pregnancies.