Heterotopic Pregnancy
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...

http://www.nejm.org/doi/full/10.1056/NEJMicm1509537#t=article
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