Ruptured Tubal Heterotopic Pregnancy with Preserved Intrauterine Pregnancy to 31 Weeks: A Case Report from the Democratic Republic of Congo.

Heterotopic pregnancy is a rare but potentially life-threatening condition defined by the simultaneous presence of an intrauterine and an ectopic pregnancy. Although uncommon in spontaneous conception, its incidence increases with ovulation induction and assisted reproductive techniques. Diagnosis remains particularly challenging in low-resource settings where access to early ultrasonography is limited. We report the case of a 30-year-old woman, gravida 3 para 0 abortion 2, who conceived after ovulation induction with letrozole. An initial ultrasound at 6 weeks of gestation confirmed an intrauterine pregnancy. Four weeks later, follow-up ultrasonography revealed a viable intrauterine pregnancy associated with hemoperitoneum and an adnexal mass suggestive of a heterotopic pregnancy. The patient presented with hypotension and tachycardia indicating hemodynamic instability. Emergency laparotomy confirmed a ruptured right tubal ectopic pregnancy with massive hemoperitoneum. Right salpingectomy was performed while carefully preserving the intrauterine pregnancy. Postoperative management included hemodynamic stabilization, antibiotics, progesterone support, and antispasmodic therapy. The postoperative course was favorable. Regular antenatal follow-up with clinical monitoring and ultrasonography was performed. At the time of reporting, the intrauterine pregnancy had progressed to 31 weeks of gestation. This case highlights the importance of maintaining clinical suspicion for heterotopic pregnancy even when an intrauterine pregnancy is confirmed, particularly in patients undergoing ovulation induction. Early recognition and prompt surgical management are essential for maternal survival and for preserving the intrauterine pregnancy.