The diagnosis of ectopic pregnancy is complicated by the wide spectrum of clinical presentations, from asymptomatic (especially in early un-ruptured cases) to acute abdomen and hemodynamic shock. Symptoms patient with ectopic pregnancy present with includes amenorrhoea, abdominal pain, vaginal bleeding, nausea,vomiting, dizziness/fainting attacks, body weakness, abdominal swelling. The classic symptom Triad of lower abdominal pain, amenorrhoea, and vaginal bleeding is present in only about 50% of patients and is most typical in patients in whom an ectopic pregnancy has ruptured. Abdominal pain is the most common presenting complaint as seen in different studies across Nigeria ranging from 80-90.7%. The diagnosis of ectopic pregnancy in reproductive age woman most times is based on clinical history which should be followed by an attentive physical examination. Evaluation of vital signs to assess for tachycardia and hypotension is pivotal in determining the patient’s hemodynamic stability. When examining the abdomen and suprapubic regions, attention should focus on the location of tenderness as well as any exacerbating factors. If voluntary/involuntary guarding of the abdominal musculature is elicited on palpation, this should raise concern for possible free fluid or other cause of peritoneal signs. Palpating a gravid uterus may suggest pregnancy, however, does not exclude other pathologies such as progressed ectopic pregnancy or heterotopic pregnancy. Patient’s presenting with vaginal bleeding would likely benefit from a pelvic examination to assess for infections as well as assess the cervical os. Bimanual pelvic examination additionally allows for palpation of bilateral adnexa to assess for any abnormal masses/structures or to elicit adnexal tenderness. A thorough history and physical examination will lend better certainty with testing obtained when evaluating for possible ectopic pregnancy.

The importance of ectopic pregnancy in developing countries and Nigeria, in particular, lies in the fact that, while the trend of early diagnosis and conservative treatment is prevalent in developed countries; we are still challenged by late presentations with the ruptured form of the ectopic pregnancy seen in more than 80% of cases [16].

Important differential diagnoses to consider with ectopic pregnancies are ovarian torsion, Tubo-ovarian abscess, appendicitis, hemorrhagic corpus luteum, ovarian cyst rupture, threatened miscarriage, incomplete miscarriage, pelvic inflammatory disease, spontaneous abortion and ureteral calculi.

Early diagnosis and treatment of this condition reduces maternal morbidity and mortality.

Diagnosing ectopic pregnancy start from taking a short and concise clinical history, detailed physical, abdominal and pelvic examination. Investigations useful in aiding the diagnosis of ectopic pregnancy include Beta subunit of human chorionic gonadotrophin, Ultrasonography and Laparoscopy.

In female patient presenting to the hospital with amenorrhoea, the first test to do is pregnancy test to check for B-hCG either in urine or serum, once it is positive, the next is to do an ultrasound of the pelvis preferably using the transvaginal route to locate where the gestational sac is. Prompt transvaginal ultrasound evaluation is key in diagnosing ectopic pregnancy. In the face of an equivocal ultrasound result I.e. where the result is not conclusive, it should be combined with quantitative beta subunit of human chorionic gonadotropin levels¹². If a patient has a beta subunit of human chorionic gonadotropin level of 1,500 mIU per mL or greater, but the transvaginal ultrasonography does not show an intrauterine gestational sac or level is between 6000-6500 mIU per ml and transabdominal ultrasonography doesn’t show an intrauterine gestational sac, ectopic pregnancy should be suspected.

Laparoscopy can function as both investigative tool as well as a treatment option. It used to be the goal standard in the diagnosis of ectopic pregnancy but since there is improved technology in the area of ultrasonography, transvaginal USS now stands as an important diagnostic tool in patients with ectopic pregnancy. TVS is readily available in most developing countries, not expensive and expertise in its use as against laparoscopy that is not within the reach of the poor. Other ancillary tests are Full blood count, Liver function test, Kidney function test, Group and cross-matching of blood.

Therapeutic management of ectopic pregnancy include: Expectant management, Medical management and Surgical management.

Expectant management

Candidates for successful expectant management should be asymptomatic and have no evidence of rupture or hemodynamic instability. Candidates should demonstrate objective evidence of resolution (eg, declining β-HCG levels).Close follow-up and patient compliance are of paramount importance, as tubal rupture may occur despite low and declining serum levels of β-HCG.

Medical management with Methotrexate

 Methotrexate is the standard medical treatment for un-ruptured ectopic pregnancy. A single-dose IM injection is the more popular regimen. The ideal candidate should have the following:  Hemodynamic stability, No severe or persisting abdominal pain, The ability to follow up multiple times, Normal baseline liver and renal function test results. Absolute contraindications to methotrexate therapy include the following: Existence of an intrauterine pregnancy, Immunodeficiency, Moderate to severe anemia, leukopenia, or thrombocytopenia, Sensitivity to methotrexate, Active pulmonary or peptic ulcer Disease, Clinically important hepatic or renal dysfunction, Breastfeeding and Evidence of tubal rupture.

Other agents that had been evaluated include prostaglandin F2ά, hyperosmolar glucose, hypertonic saline and potassium chloride.

Surgical management

 Before the advent of laparoscopy, laparotomy with salpingectomy (removal of the fallopian tube through an abdominal incision) was the standard therapy for managing ectopic pregnancy. Laparoscopy has become the recommended surgical approach in most cases. Laparotomy is usually reserved for patients who are hemodynamically unstable or for patients with cornual ectopic pregnancies; it also is a preferred method for surgeons inexperienced in laparoscopy and in patients in whom a laparoscopic approach is difficult. Laparoscopy with salpingostomy, without fallopian tube removal is also a method of surgical treatment. Laparoscopy has similar tubal patency and future fertility rates as medical treatment. The risk of recurrent ectopic pregnancy is 12-18%, with the future risk increasing further with every successive occurrence.

The follow up in patients managed for ectopic pregnancy depends on the treatment option used. For patients who were managed expectantly or with methotrexate should go to the hospital for quantitative  β-HCG measurement every 48hours because the doubling time for this in normal pregnancy is 48hours, this is to ensure that treatment option chosen is working out or if there is need for another option. Those who had their ectopic pregnancy managed surgically should go for follow up 2-3weeks after for repeat test to rule out persistence of the β-HCG in them.

Following an ectopic pregnancy, it is pertinent to counsel the patient appropriately on the chances of recurrence and the need to present early for pregnancy localization in her next pregnancy.

There is no way ectopic pregnancy can be prevented, however, the risk factors to having ectopic pregnancy can be reduced.Such as reducing/limiting the number of sexual partners, preventing sexually transmitted infections or prompt  treatment once contracted to reduce damage to the fallopian tubes, using barrier contraception such as condom to reduce the risk of STI/PID,quit smoking, early presentation to hospital once a female in reproductive age missed her menses for testing.

Ectopic pregnancy is a major cause of maternal morbidity and mortality in sub-Saharan Africa. Early diagnosis through ultrasound and prompt intervention are critical to prevent life-threatening complications such as rupture and internal bleeding. Limited access to healthcare and diagnostic tools in rural areas often delays diagnosis, increasing the risks. Improving awareness, enhancing healthcare infrastructure, and ensuring timely surgical or medical management can significantly reduce mortality associated with ectopic pregnancy in the region.