Tehran University of Medical Sciences Case Reports in Clinical Practice 2538-2683 10 2 2025 10 15 75 78 EN Behrokh Sahebdel Department of Obstetrics and Gynecology, Maternal Fetal and Neonatal Research Center, Yas Hospital complex, Tehran University of Medical Sciences, Tehran, Iran. Mohammad Hossein Golzar Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Tehran University of Medical Sciences, Tehran, Iran. Azita Zare Department of Obstetrics and Gynecology, Maternal Fetal and Neonatal Research Center, Yas Hospital complex, Tehran University of Medical Sciences, Tehran, Iran. Fatemeh Golshahi Department of Obstetrics and Gynecology, Maternal Fetal and Neonatal Research Center, Yas Hospital complex, Tehran University of Medical Sciences, Tehran, Iran. Nafiseh Saedi Department of Obstetrics and Gynecology, Maternal Fetal and Neonatal Research Center, Yas Hospital complex, Tehran University of Medical Sciences, Tehran, Iran. Mahboobeh Shirazi Department of Obstetrics and Gynecology, Maternal Fetal and Neonatal Research Center, Yas Hospital complex, Tehran University of Medical Sciences, Tehran, Iran. 2025 07 14 2025 08 25 Heterotopic pregnancy is the simultaneous presence of intrauterine and ectopic gestations. It is typically diagnosed in the first trimester via sonography or when patients present with vaginal bleeding or abdominal pain. We report a case of a 26-year-old Asian primigravida woman who conceived through ovulation induction and presented at 19 weeks and 4 days of gestation—one week after a successful Macdonald cerclage, with severe abdominal pain and hemodynamic instability. Bedside ultrasound revealed significant hemoperitoneum and a viable intrauterine fetus. Emergency laparotomy identified an unruptured right fallopian tube containing a 5 × 6 cm mass. A right salpingectomy was performed due to suspected ectopic pregnancy, and no other bleeding source was found. Histopathology confirmed tubal ectopic pregnancy. The postoperative course was uneventful, and the intrauterine pregnancy successfully progressed to term. Heterotopic pregnancy should be considered in the differential diagnosis of hemoperitoneum, even in the second trimester. https://crcp.tums.ac.ir/index.php/crcp/article/view/1070 https://crcp.tums.ac.ir/index.php/crcp/article/download/1070/720