Spontaneous heterotopic pregnancy presenting with hemorrhagic shock in a multiparous woman: A case report and literature review

Heterotopic pregnancy, the coexistence of an intrauterine and an ectopic gestation, remains a rare but potentially life-threatening condition in spontaneous conceptions. Its diagnosis is often delayed due to the misleading reassurance provided by the confirmation of an intrauterine pregnancy. We report the case of a 41-year-old gravida 6, para 3 woman with a history of triple-scarred uterus and prior ectopic pregnancy, who presented in hemorrhagic shock at 5 weeks and 4 days of gestation. Initial transabdominal ultrasound identified an intrauterine gestational sac and a suspected ruptured adnexal mass. Emergency exploratory laparotomy revealed a ruptured right tubal ectopic pregnancy with massive hemoperitoneum. A right salpingectomy and hemostatic uterine curettage were performed, and the patient was transferred to intensive care for stabilization. This case illustrates the diagnostic challenge of heterotopic pregnancy in spontaneous conception, the importance of systematic adnexal assessment even after identifying an intrauterine pregnancy, and the need for urgent surgical intervention in hemodynamically unstable patients. Preservation of the intrauterine pregnancy remains a primary consideration when feasible; however, maternal stabilization is paramount. Early recognition and prompt surgical management are essential to reduce morbidity and mortality associated with heterotopic pregnancy. Increased vigilance is warranted, particularly in patients with risk factors such as prior ectopic pregnancy or tubal pathology.