When an Intrauterine Pregnancy Is Not Reassuring: Spontaneous Heterotopic Pregnancy With Tubal Rupture

Heterotopic pregnancy (HP), defined as the co-existence of intrauterine and ectopic gestations, is a rare but potentially life-threatening condition. While its incidence has increased with the widespread use of assisted reproductive technologies (ARTs), spontaneous HP remains uncommon and may be overlooked when an intrauterine pregnancy (IUP) is identified. We report the case of a 22-year-old multi-parous woman who presented at 5 weeks and 3 days of amenorrhea with acute pelvic pain, mild vaginal bleeding, hypotension, and signs of an acute abdomen. Transvaginal ultrasonography (TVUS) demonstrated a non-viable IUP, a right adnexal gestational sac containing a yolk sac, and free fluid in the pouch of Douglas. Emergency laparotomy revealed a ruptured right tubal ectopic pregnancy (EP) with hemoperitoneum. Right salpingectomy and uterine curettage were performed, and histopathological examination confirmed HP. The post-operative course was uneventful. A review of recently published cases indicates that abdominal pain and vaginal bleeding are the most common presenting symptoms, with tubal implantation representing the predominant ectopic location. Clinicians should maintain a high index of suspicion for HP in symptomatic early pregnancies, regardless of risk factors or confirmation of an intrauterine gestation. Prompt diagnosis and timely surgical management are essential to reduce maternal morbidity and prevent life-threatening complications.