The aim of this study was to elucidate the clinical presentation of ectopic pregnancy in the emergency department and highlight the atypical presentations and pitfalls in its diagnosis. This was a 4-year retrospective descriptive study carried out at a tertiary teaching hospital. Two hundred and seven cases of ectopic pregnancy treated in a tertiary teaching hospital were reviewed. Among the risk factors, 4.9% had a history of tubal ligation. Two patients developed ectopic pregnancy while breastfeeding. Of the patients, 43.7% did not have the triad symptoms of lower abdominal pain, vaginal bleeding and amenorrhoea. One patient presented with rectal bleeding while three patients presented with epigastric pain and central abdominal pain instead of lower abdominal pain. All who had tachycardia (10.4% of all cases) had ruptured ectopic pregnancy. Of the cases, 30% and 49% did not have abdominal pain and rebound tenderness respectively; 37.5% had negative cervical motion tenderness; 3.1% and 2.6% of cases had negative urine HCG and plasma beta HCG tests respectively. Ultrasound missed 1.6% of ectopic pregnancies. Missed pregnancy, normal ultrasound study and diagnosis of other gynaecological conditions were reasons for the delayed diagnosis of 5.8% of cases. There was one mortality. Any female in the reproductive age group with syncope, abdominal symptoms or any of the components of the classical triad must have ectopic pregnancy excluded. Patients with normal ultrasound studies should have their serum beta HCG levels and ultrasound scans repeated until the condition can be completely excluded. Transabdominal or transvaginal ultrasound studies done within the emergency department would enable earlier diagnosis and management.