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.

• Anemia

  The patient was hypotension, had anemia and signs of lower abdominal peritonitis. Initial diagnosis was tubal pregnancy with rupture. Intraoperatively, there were hemoperitoneum and two fetuses were found in the pelvis. [ncbi.nlm.nih.gov]

  Postoperatively, iron therapy for anemia may be necessary during convalescence. Rho(D) immune globulin (300 mcg) should be given to Rh-negative patients because sensitization may occur. Tubal pregnancy can end up with abortion or rupture. [symptoma.com]

  Diseases that increase the risk of obstetrical complications include diabetes, heart disease, hypertension, kidney disease, and anemia. rubella (German measles) can be responsible for many types of birth defects, particularly if the mother contracts it [medical-dictionary.thefreedictionary.com]

  When the placenta is left in place, it is necessary to keep watch over the appearance of the following maternal complications in postoperative period: bowel obstruction, infection, hemorrhage, anemia, fistula, [1, 9, 13] etc. [bmcpregnancychildbirth.biomedcentral.com]

• Abdominal Pain

  Gynecologists should always consider the possibility of ectopic pregnancy in pregnancies following IVF-ET, particularly in cases with tubal disease and abdominal pain. [ncbi.nlm.nih.gov]

• Acute Abdomen

  A 25-year-old woman, gravida 2, parity 0, presented with acute abdomen after 12 weeks of amenorrhea. Simultaneous right tubal pregnancy and twisted left ovarian cyst were intraoperatively diagnosed. [ncbi.nlm.nih.gov]

  This situation is evident in case number two, whereby the patient presented at 7-weeks gestation with an acute abdomen. She had haemoperitoneum of 2 litres and required transfusion with 3 units of blood. [hindawi.com]

  It is important to perform daily abdominal examination and closely monitor the vital signs to ensure a patient is responding to antibiotic therapy, and is not developing an acute abdomen or early sepsis. [cancertherapyadvisor.com]

  Peritonism and signs of an acute abdomen may occur. Women with a positive pregnancy test and any of the following need to be referred immediately to hospital: Pain and abdominal tenderness. Pelvic tenderness. Cervical motion tenderness. [web.archive.org]

  A patient with spotting, no abdominal pain, and a low initial beta–human chorionic gonadotropin (β-HCG) level that is falling may be managed expectantly, whereas a patient who presents with hemodynamic instability, an acute abdomen, and high initial β-HCG [emedicine.medscape.com]

• Pelvic Mass

  After surgery, the serum beta-human chorionic gonadotropin (β-HCG) level was regularly detected, and B ultrasound was used to monitor the pelvic mass change. [ncbi.nlm.nih.gov]

  Typically seen as thick-walled fluid-filled pelvic mass(es) 12 T1: abscess contents typically hypointense T2: abscess contents typically heterogeneous signal or hyper-intense Treatment and prognosis Initial treatment can be with antibiotic therapy. [radiopaedia.org]

  Last year, a transvaginal ultrasound had been performed by the gynecologist for a palpable pelvic mass, but only endometrial hyperplasia was impressed. [bmcwomenshealth.biomedcentral.com]

  The current pregnancy represents a chronic tubal pregnancy (a tubal pregnancy in which the tubal wall gradually disintegrates, with slow and/or repeated episodes of hemorrhaging leading to the formation of a pelvic mass). [merckmanuals.com]

• Right Lower Quadrant Tenderness

  On physical examination, the patient is febrile to 102.4 F, abdominal exam reveals right lower quadrant tenderness and labs are significant for WBC of 13,000. [emdocs.net]

• Back Pain

  Low back pain. Mild pain in the abdomen or pelvis. Mild cramping on one side of the pelvis. If you have any of these symptoms, you should call your doctor. As an ectopic pregnancy grows, it may rupture. Then you may experience more serious symptoms. [familydoctor.org]

  pain If you experience any of these symptoms you should go directly to the emergency room. [everydayfamily.com]

• Low Back Pain

  Low back pain. Mild pain in the abdomen or pelvis. Mild cramping on one side of the pelvis. If you have any of these symptoms, you should call your doctor. As an ectopic pregnancy grows, it may rupture. Then you may experience more serious symptoms. [familydoctor.org]

  However, as it advances, ectopic pregnancy shows some abnormal symptoms like abnormal vaginal bleeding, pelvic pain, and low back pain. [youtube.com]

  Common symptoms of an ectopic pregnancy include: Vaginal bleeding Signs of early pregnancy Lower abdominal or pelvic pain Dizziness or weakness Low back pain If the Fallopian tube ruptures, the pain and bleeding could be severe enough to cause fainting [my.clevelandclinic.org]

  back pain Cramping on one side of the pelvis If the areas around the ectopic pregnancy rupture and bleed, symptoms may worsen and include: Low blood pressure Pain in the shoulder area, due to blood leaking from the fallopian tube Urge to have a bowel [heartbeatinternational.org]

• Vaginal Bleeding

  A previously asymptomatic woman presented with pelvic pain and vaginal bleeding at 4 months' gestation and was found to have a live, 14-week, tubal pregnancy. [ncbi.nlm.nih.gov]

• Pelvic Pain

  A previously asymptomatic woman presented with pelvic pain and vaginal bleeding at 4 months' gestation and was found to have a live, 14-week, tubal pregnancy. [ncbi.nlm.nih.gov]

• Adnexal Mass

  However, the diagnosis is often not that simple, especially when the patient presents early, has minimal pain, is haemodynamically stable, and TVS shows an empty uterus but no obvious adnexal mass. [ncbi.nlm.nih.gov]

  mass that is separate from the ovary is the most common finding, and may be seen on in up to 89-100% of cases 4 the presence of an adnexal mass becomes more specific for an ectopic pregnancy when it contains a yolk sac or a living embryo or when it moves [radiopaedia.org]

  The presence of an adnexal mass in the absence of an intrauterine pregnancy on transvaginal sonography (LR 111; 95% CI, 12-1028; n 6885), and the physical examination findings of cervical motion tenderness (LR 4.9; 95% CI, 1.7-14; n 1435), an adnexal [doi.org]

  The latter scenario may include an intrauterine pregnancy with a hemorrhagic corpus luteum cyst or an intrauterine pregnancy with an adnexal mass, as can be found with concurrent appendicitis. [emedicine.com]

• Adnexal Tenderness

  tenderness (LR 1.9; 95% CI, 1.0-3.5; n 1435) all increase the likelihood of ectopic pregnancy. [doi.org]

  The most common physical exam findings are bilateral adnexal tenderness and purulent cervical discharge. Cervical motion, uterine, and lower abdominal tenderness may also be present. [saem.org]

  Bimanual examination suggested uterine tenderness and bilateral adnexal tenderness. There were no obviously palpable masses. [journals.lww.com]

  Mucopurulent (green or yellow) discharge on speculum examination and acute cervical motion tenderness, uterine or adnexal tenderness are indicative for PID and TOA. [cancertherapyadvisor.com]

• Vaginal Discharge

  There was a slight vaginal discharge of dark blood. The same physician was consulted, but no treatment was prescribed save rest [jamanetwork.com]

  Vaginal discharge with an odor, painful urination or bleeding between menstrual cycles can be associated with a sexually transmitted infection (STI). If these signs and symptoms occur, stop having sex and see your doctor soon. [mayoclinic.org]

  Classic Presentation Women typically present with bilateral lower abdominal pain, purulent vaginal discharge, or less frequently with abnormal vaginal bleeding. [saem.org]

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.

• Blood tests: All relevant serum levels including β-human chorionic gonadotropin (β-hCG) are at a lower range than the expected in a normal pregnancy. Monitoring β-hCG levels is important. Decreased levels over a period of time can be an indicator of spontaneous abortion.
• Transvaginal ultrasound (TVS): β-hCG titers and ultrasound complement each another in early detection of tubal pregnancy. When β-hCG levels are around 1000 mIU/mL TVS detects a well visible intrauterine sac. When an empty sac is seen with or without adnexal mass at same β-hCG levels, ectopic pregnancy can be suspected [8].

• Ovarian Mass

  The terminal portion of the appendix was engulfed in this tubo-ovarian mass (Fig. 1, 2 ) and was released by sharp dissection. [casesjournal.biomedcentral.com]

  mass is related to the development of torsion. [en.wikipedia.org]

  masses, and peritoneal and serosal thickening and enhancement. [radiopaedia.org]

  TOA was strongly suspected, and the patient underwent transvaginal ultrasonography, which demonstrated an 11.1 7.9 cm left ovarian cystic mass with low echogenicity, and a 6.3 4.4 cm right ovarian mass with a similar echo-texture (Fig. 2). [surgicalcasereports.springeropen.com]

• Beta-HCG Increased

  However, other women have latent ectopic pregnancy with low beta-hCG levels, and longer time intervals since the last menstrual period, and they present few symptoms. 12 During the first six weeks of amenorrhea, serum beta-hCG increases exponentially, [scielo.br]

• Trophoblastic Cells

  Our results suggest that SWAP-70 may be involved in regulating migration and invasion of trophoblast cells during the processes of embryonic implantation and placentation in primates. [ncbi.nlm.nih.gov]

  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. [symptoma.com]

• Medical therapy: All patients with tubal pregnancy must be closely monitored. In a stable patient, methotrexate (50 mg/m2) intramuscularly can be given as single or multiple doses for early tubal pregnancy. The pregnancy should be < 3.5 cm in largest dimension and unruptured, with no active bleeding and no fetal heart tones. The use of methotrexate in an unstable patient is absolutely contraindicated [9].
• Surgical therapy: Surgical treatment is definitive, and can be planned for all cases but is absolutely indicated for an unstable patient with a tubal pregnancy. The patient is hospitalized, and blood is typed and cross-matched. Diagnostic laparoscopy is the initial surgical procedure performed. The plan of surgery depends on size of the ectopic pregnancy. Removal of fallopian tube either partially or completely along with ectopic is planned accordingly [10]. 
• Postoperatively, iron therapy for anemia may be necessary during convalescence. Rho(D) immune globulin (300 mcg) should be given to Rh-negative patients because sensitization may occur.

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 [6] [7].

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 [2] [3].

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 [4].

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 [5].

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 [1].  

• Definition: A tubal pregnancy is when a fertilized egg implants itself outside of the womb, in one of the fallopian tubes. The egg thus implanted cannot grow into a baby, and also poses danger to the woman’s health because of the possibility of the tube getting ruptured. 
• Cause: Factors causing tubal dysfunction lead to inability of the fertilized egg to move to the womb from the fallopian tube. These include previous infection of tubes, pelvic inflammatory disease (PID) which may be due to various causes including sexually transmitted diseases, problems of the appendix and previous tubal surgery. 
• Symptoms: Symptoms appear between the fifth and fourteenth weeks of pregnancy, and include missed periods, mild to severe pain in abdomen, usually on one side and abnormal vaginal bleeding. Sometimes a tubal pregnancy may not cause any noticeable symptoms except those of pregnancy and may be diagnosed during routine pregnancy testing. In case of rupture, there is a sudden severe pain, feeling of nausea and faintness, and sometimes diarrhea and pain in shoulder tip. Rupture causes massive internal bleeding and can be life threatening. 
• Diagnosis: The best way to diagnose a tubal pregnancy is by doing an ultrasound examination of the reproductive organs with the help of a probe placed inserted into the vagina. 
• Treatment and follow-up: Tubal pregnancy, when detected very early, may be managed with a drug called methotrexate. Methotrexate prevents the egg from developing and the pregnancy tissue is then absorbed into the body. A later diagnosis of tubal pregnancy requires surgery to remove the egg, which is usually done with the help of a laparoscope. 

1. Murray H, Baakdah H, Bardell T, Tulandi T. Diagnosis and treatment of ectopic pregnancy. CMAJ 2005; 173:905.
2. Bouyer J, Coste J, Shojaei T, et al. Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case-control, population-based study in France. Am J Epidemiol 2003; 157:185.
3. Pisarska MD, Carson SA, Buster JE. Ectopic pregnancy. Lancet 1998; 351:1115.
4. Zane SB, Kieke BA Jr, Kendrick JS, Bruce C. Surveillance in a time of changing health care practices: estimating ectopic pregnancy incidence in the United States. Matern Child Health J 2002; 6:227.
5. Senterman M, Jibodh R, Tulandi T. Histopathologic study of ampullary and isthmic tubal ectopic pregnancy. Am J Obstet Gynecol 1988; 159:939.
6. Clausen I. Conservative versus radical surgery for tubal pregnancy. A review. Acta Obstet Gynecol Scand. Jan 1996; 75(1):8-12.
7. Ory SJ, Nnadi E, Herrmann R, O'Brien PS, Melton LJ 3rd. Fertility after ectopic pregnancy. Fertil Steril. Aug 1993; 60(2):231-5
8. Kirk E, Papageorghiou AT, Condous G, et al. OC59: A single transvaginal ultrasound examination as a test for ectopic pregnancy. Ultrasound Obstet Gynecol. 2007; 30:385.
9. Lipscomb GH. Medical therapy for ectopic pregnancy. Semin Reprod Med 2007; 25:93.
10. Mol F, van Mello NM, Strandell A, et al. Salpingotomy versus salpingectomy in women with tubal pregnancy (ESEP study): an open-label, multicentre, randomised controlled trial. Lancet 2014; 383:1483.