Tubal pregnancy refers to the implantation of a fertilized egg in the fallopian tubes. The most common site of implantation is the ampulla.
Severe lower quadrant pain, sudden in onset, stabbing, intermittent and without radiation, is present in almost 100% cases. Pain can be unilateral or bilateral, localized or generalized. Backache may be present during attacks. Secondary amenorrhea varies, as nearly half of women with tubal pregnancies have some spotting at the time of their expected menses and thus do not realize they are pregnant.
Abdominal distention and mild paralytic ileus are often seen. Palpable mass in the pelvic region, and diffuse abdominal tenderness is noticed. Uterine changes of pregnancy and peritoneal accumulation of blood may be present. Heavy intraabdominal bleed can lead to altered consciousness. Vital signs should be examined to assess the hemodynamic stability of the patient.
The key components to the diagnosis of tubal pregnancy include physical findings, transvaginal ultrasonography (TVS), serum β-hCG level measurement – both the initial and the subsequent patterns of rise or decline, and diagnostic surgery, which includes curettage, laparoscopy, and occasionally laparotomy.
Tubal pregnancy can end up with abortion or rupture. The mortality from tubal pregnancy is around 0.2 per 100 cases. Isthmic pregnancies tend to rupture earliest, at 6 to 8 weeks' gestation. Interstitial pregnancies are the last to rupture, usually at 12–16 weeks and can result in massive hemorrhage due to their proximity to uterine and ovarian vessels. More than 85 % of women can be diagnosed with accurate determination of low β-hCG and diagnostic ultrasound, allowing preservation of tube and future fertility. There is a 10 to 20% chance of another ectopic pregnancy, and the patient requires careful observation and early ultrasound confirmation of an intrauterine pregnancy in the future  .
Predisposing risk factors are found in only two third of cases. Tubal pregnancy is more often associated with fertility treatments and intrauterine contraceptive devices (IUD). Tubal surgery, reanastomosis of tubectomy, previous ectopic pregnancy, in-utero exposure to diethylstilbestrol, documented tubal pathology and use of IUD are high risk factors. Infertility, previous genital infections, and multiple sexual partners are associated with moderate risk of tubal pregnancy. Smoking and past surgeries are also risk factors. Multiple previous elective abortions and failure of progesterone only contraceptives are important associations  .
The rate of ectopic pregnancy is approximately 1 % of pregnancies. The mortality rate is high in women who do not have access to medical care. Undiagnosed or undetected ectopic pregnancy is the most common cause of maternal death during the first trimester in many developed countries .
The implantation in tubal pregnancy takes place under the serosa inside the connective tissue of the fallopian tube. There is little decidual reaction to the permeating trophoblast leading it to invade blood vessels causing local hemorrhage. As the pregnancy progresses, the hematoma in the subserosal space enlarges. Progressive distention of the tube eventually leads to rupture. Tubal pregnancy includes ampullary type (55%), isthmic type (25%), fimbrial type (17%) and interstitial type. Uterine decidual sloughing can lead to vaginal bleeding. Superficial secretory endometrium usually is present, but no trophoblastic cells are seen .
A large number of tubal pregnancies can be avoided by prevention and timely treatment of sexually transmitted diseases. It is important to maintain a high index of suspicion in case of suggestive symptoms and diagnose tubal pregnancies early to reduce morbidity, mortality and late sequelae.
A tubal pregnancy occurs when a fertilized ovum implants in the fallopian tube instead of the endometrial lining of the uterus. It is the most common type of ectopic pregnancy. Other sites of ectopic implantation are the peritoneum or abdominal viscera, the ovary, and the cervix.
Tubal pregnancy commonly presents with abdominal and pelvic pain, missed period and vaginal bleeding. Diagnosis is made with a transvaginal ultrasound. Tubal pregnancy requires an emergency management to prevent the potentially life-threatening complication of tubal rupture. Medical management includes systemic methotrexate and surgical treatment consists of laparoscopic salpingectomy .