A 34-year-old woman with a history of appendectomy presented to the emergency department after 45 minutes of acute abdominal pain. Her last menstrual period was 9 weeks before presentation, and a normally conceived intrauterine pregnancy (8 weeks of gestation) had been diagnosed by her gynecologist by means of ultrasonography (Panel A, arrow). On examination, she had hypotension, tachycardia, and appreciable tenderness in the right lower abdomen. Transvaginal ultrasonography revealed a 4-cm-by-4-cm right adnexal mass (Panel B, arrow) and intrauterine pregnancy (Panel C, arrow), as well as free fluid in the peritoneal cavity (Panel C, arrowhead), which caused concern about an ectopic pregnancy. An urgent laparoscopy was performed. On laparoscopy (Panel D), a ruptured ectopic pregnancy was seen in the right fallopian tube (arrowhead), and an intact gestational sac (white arrow) and embryo (black arrow) were also seen. Large hemoperitoneum was present, with active bleeding from the ruptured site in the fallopian tube. A salpingectomy was performed. Heterotopic pregnancy is the rare occurrence of a simultaneous intrauterine and extrauterine pregnancy. The incidence of heterotopic pregnancy in natural conception is estimated to be 1 in 30,000 pregnancies. In this case, the intrauterine pregnancy remained intact, and a healthy girl was delivered at term.