↓ Figure 1. Transvaginal ultrasound demonstrating an intrauterine embryo with a CRL of 8.5 mm and absent cardiac activity, consistent with missed abortion. CRL: crown-rump length.
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Case Report
Volume 17, Number 10, October 2026, pages 590-598
When an Intrauterine Pregnancy Is Not Reassuring: Spontaneous Heterotopic Pregnancy With Tubal Rupture
Figures
Tables
| Variable | Findings |
|---|---|
| G4P3: gravida 4 para 3; EP: ectopic pregnancy; CRL: crown-rump length; IUP: intrauterine pregnancy; HR: heart rate; BP: blood pressure; TVUS: transvaginal ultrasound. | |
| Age | 22 years |
| Gravidity/parity | G4P3 |
| Conception | Spontaneous |
| Risk factors for EP | None identified |
| Symptoms | Lower abdominal pain, vaginal bleeding |
| Hemodynamic status | BP 90/70 mm Hg, HR 110 bpm |
| TVUS findings (IUP) | CRL 8.5 mm (6 + 5 weeks), absent cardiac activity |
| TVUS findings (EP) | Right adnexal gestational sac with yolk sac (6 weeks) |
| Associated findings | Free fluid in pouch of Douglas/hemoperitoneum |
| Diagnosis | Spontaneous heterotopic pregnancy with ruptured right tubal ectopic pregnancy and missed abortion |
| Surgical treatment | Exploratory laparotomy + right salpingectomy + uterine curettage |
| Histopathology | Confirmed tubal ectopic pregnancy with chorionic villi |
| Author | Age | Risk factors | GA at diagnosis | Presentation | Ectopic location | Rupture | IUP outcome | Management |
|---|---|---|---|---|---|---|---|---|
| IUP: intrauterine pregnancy; NA: not available; PID: pelvic inflammatory disease; US: ultrasound; GTD: gestational trophoblastic disease; GA: gestational age. | ||||||||
| Bouab M, 2024 [5] | 28 | None | 10 weeks | Acute pelvic pain, vaginal bleeding | Tubal | Ruptured | Miscarriage | Salpingectomy |
| Nguyen KP, 2022 [6] | 27 | None | 5 + 5 weeks | Acute pelvic pain, vaginal bleeding | Tubal | Ruptured | Early pregnancy loss at 8 weeks | Laparoscopic salpingectomy |
| Dao D, 2023 [7] | NA | None | NA | Acute pelvic pain, vomiting | Tubal | Non-ruptured | Termination by patient’s desire | Laparoscopic salpingectomy |
| Valencia V, 2024 [8] | 37 | None | 7 weeks | Acute abdominal pain, vaginal bleeding | Tubal | Non-ruptured | NA | Salpingectomy |
| Lober R, 2024 [9] | 36 | None | 6 weeks | Acute abdominal pain | Ovarian | Ruptured | Vaginal delivery at 38 weeks | Laparoscopic removal of the ovarian mass |
| Khouloud M, 2024 [10] | 36 | None | 12 weeks | Pelvic tenderness, vaginal bleeding | Abdominal | Non-ruptured | Miscarriage at 6 weeks | Laparotomy |
| Maharjan S, 2023 [11] | 28 | None | 8 + 3 weeks | Abdominal pain, vaginal spotting | Tubal | Non-ruptured | Vaginal delivery at 38 weeks | Laparoscopic salpingectomy |
| Momtahan M, 2021 [12] | 31 | PID | 36 + 4 weeks | Labor pain | Abdominal | Alive fetus weighing 2,200 g | Cesarean section | Operational delivery of both fetuses |
| Ouafidi B, 2021 [13] | 32 | None | 9 + 2 weeks | Acute pelvic pain | Tubal | Ruptured | Vaginal delivery at 37 + 5 weeks | Salpingectomy |
| Maree G, 2022 [14] | 37 | None | 12 weeks | Lower abdominal pain, intermittent vaginal bleeding | Ovarian | Non-ruptured | Uterine curettage | Ovarian excision |
| Abdelmonem AH, 2021 [15] | 38 | None | 9 + 5 weeks | Abdominal pain, nausea, vomiting | Tubal | Non-ruptured | NA | Laparoscopic salpingectomy |
| Wang F, 2025 [16] | 36 | None | 12 weeks | Abdominal pain | Tubal | Ruptured | Termination by patient’s desire | Laparoscopic salpingectomy |
| Regragui A, 2025 [17] | 41 | Prior tubal pregnancy | 5 + 4 weeks | Signs of hemorrhagic shock | Tubal | Ruptured | Uterine curettage due to missed abortion | Salpingectomy |
| Kathopoulis N, 2023 [18] | 26 | None | 17 + 2 weeks | Lower abdominal pain | Tubal | Ruptured | Cesarean section at 38 weeks | Laparoscopic salpingectomy |
| Guraslan H, 2024 [19] | 29 | NA | 7 + 6 weeks | Asymptomatic | Cesarean scar pregnancy | Non-ruptured | Cesarean section at 38 weeks | Laparoscopic excision of the scar pregnancy |
| Tariq Ahmed Alabsi M, 2024 [20] | 34 | None | 5 + 5 weeks | Asymptomatic | Cesarean scar pregnancy | Non-ruptured | Cesarean section at 38 weeks | Spontaneous resolution of the scar pregnancy |
| Takoutsing B, 2025 [21] | 31 | None | 11 + 6 weeks | Crampy abdominal pain, vaginal spotting | Tubal | Ruptured | NA | Salpingectomy |
| Nasrollahi F, 2024 [22] | 28 | None | 8 weeks | Shortness of breath, chest and abdominal pain, syncope | Tubal | Ruptured | Term delivery | Salpingectomy |
| Rodriguez MS, 2026 [23] | 33 | None | 7 + 1 weeks | Pelvic pain, vaginal bleeding | Tubal | Non-ruptured | Cesarean section at 38 weeks | Laparoscopic salpingectomy |
| Dubbewar A, 2022 [24] | 40 | None | NA | Abdominal pain | Tubal | Ruptured | Evacuation due to GTD | Laparoscopic salpingectomy |
| Teka H, 2023 [25] | 26 | None | 7 + 5 weeks | Abdominal pain | Tubal | Ruptured | Viable IUP | Salpingo-oophorectomy |
| Ozawa N, 2021 [26] | 36 | None | 5 + 6 weeks | Abdominal pain | Abdominal | Ruptured | Term delivery | Extraction of the abdominal mass |
| Kansal M, 2023 [27] | 27 | None | 6 + 5 weeks | Pelvic pain | Tubal | Non-ruptured | Term delivery | Laparoscopic salpingectomy |
| Prucha Leite N, 2025 [28] | 38 | None | 8 + 5 weeks | Acute pelvic pain, signs of hypovolemic shock | Tubal | Ruptured | Uterine curettage | Laparoscopic salpingectomy |
| Areys HM, 2025 [29] | 22 | Female genital mutilation | 10 + 2 weeks | Lower abdominal pain, vomiting | Tubal | Ruptured | Term delivery | Salpingectomy |
| Maduako KT, 2022 [30] | 25 | None | 8 weeks | Acute abdominal pain, vomiting | Tubal | Ruptured | Cesarean section at 37 + 5 weeks | Salpingectomy |
| Kunarathnam V, 2026 [31] | 26 | None | 10 + 6 weeks | Acute abdominal pain | Tubal | Non-ruptured | Term delivery | Laparoscopic salpingectomy |
| Koutras, A, 2021 [32] | 30 | None | 7 + 4 weeks | Acute abdominal pain, vaginal bleeding | Cervical | Non-ruptured | Uterine curettage | Uterine curettage followed by Foley balloon catheter in cervical canal and vaginal ligation of cervical arteries |
| Principi G, 2026 [33] | 31 | None | 6 + 5 weeks | Vaginal bleeding | Cervical | Non-ruptured | Cesarean section at 38 + 6 weeks | US-guided cervical curettage |
| Herrera Castañeda E, 2025 [34] | 35 | None | 9 weeks | Generalized abdominal pain | Cornual | Ruptured | Cesarean section at 39 weeks | Cornual resection |
| Galatis D, 2025 [35] | 29 | None | 8 weeks | Abdominal pain, vaginal bleeding | Tubal | Ruptured | NA | Salpingectomy |
| Condition | Overlapping features with HP | Distinguishing clues |
|---|---|---|
| HP: heterotopic pregnancy; IUP: intrauterine pregnancy. | ||
| Threatened miscarriage | Pelvic pain, vaginal bleeding | Adnexal mass, free fluid, persistent pain disproportionate to IUP findings |
| Hemorrhagic corpus luteum cyst | Adnexal pain, complex adnexal mass | Imaging evolution, ectopic sac/yolk sac, hemoperitoneum pattern |
| Isolated ectopic pregnancy | Pelvic pain, bleeding | Presence of concurrent IUP in HP |
| Ruptured ovarian cyst | Acute pain, intraperitoneal fluid | Absence of ectopic gestational structures |
| Ovarian torsion | Acute abdominal pain, adnexal tenderness | Doppler findings, enlarged ovary |
| Appendicitis | Lower abdominal pain | Gastrointestinal symptoms, inflammatory markers |