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Background: Lack of early ultrasound examination and proper antenatal care in rural areas explain why most ectopic pregnancies are presented to our center only after they become disturbed. However, this is almost always restricted to the first trimester. Case: A middle aged woman presented with acute abdomen and hemodynamic instability was admitted at our emergency department. History revealed an unexpected definite period of amenorrhea of 18 weeks and 2 days duration and pregnancy test was found positive. Ultrasound examination showed hemoperitoneum and a right large adnexal swelling with a viable fetus inside and as such immediate exploration was decided. Laparotomy revealed profound intra-abdominal and pelvic blood collection and an advanced right tubal pregnancy with intact gestational sac. Right salpingectomy was done and the patient had a smooth postoperative course until being discharged. Conclusion: According to this case, tubal pregnancy should always be considered even in the second trimester if the clinical presentation is relevant, and ultrasound examination is mandatory to identify pregnancy location.